Injecting Drug Users in Bulgaria

TIHOMIR BEZLOV CAS BARENDREGT

INJECTING DRUG USERS IN BULGARIA

Profile and risks

Initiative for Health Foundation

Sofia 2004

1 This study was conducted with the joint efforts of Addiction Research Institute IVO - Rotterdam; Initiative for Health Foundation - Sofia; Panacea Foundation - Plovdiv; Doze of Love Association - Bourgas; Pleven 21-st Century Foundation - Pleven.

The research team consist of Tihomir Bezlov (senior researcher), Cas Barendregt (senior researcher), Agnes van der Poel (expert), Atanas Rusev (local researcher), Atanas Louizov (local researcher), Dimitar Grancharov, Julian Marinov (local researcher),Mitko Stamatov (local researcher).

IVO, Addiction Research Institute Initiative for Health Heemraadssingel 194 Foundation 3021 DM Rotterdam 52A, Todor Kableshkov Str. The Netherlands 1680 Sofia, Bulgaria Phone ++31104253366 Phone/Fax +35929550472 Fax ++31102763988 E-mail [email protected] E-mail [email protected] www.initiativeforhealth.org

Panacea Foundation Pleven 21-st Century 19, Bojidar Zdravkov Str. Foundation 4006 Plovdiv, Bulgaria 23, D. Konstantinov Str. Tel/fax: +359 32 626 379 5800 Pleven, Bulgaria e-mail: [email protected] Tel/fax: +3596800271 e-mail: [email protected]

Doze of Love Association 17, Graf Ignatief Str. 8000 Bourgas, Bulgaria Phone/ Fax +35956841488 E-mail: [email protected]

ISBN 954-91430-5-8 Design: Kostadin Kutrjanov Printing: IFO Design / www.ifodesign.net

2 CONTENTS

Introduction 5

Design, methodology and background of the survey 7

1. Demographic and socio-economic profile of the injection drug users 9 1.1. Demographic characteristics 9 1.2. Socio-economic profile 16 1.3. Contacts with public institutions 22

2. Drug use, patterns, sources, mobility with IDU 24 2.1. Patterns of use by psychoactive substances (PAS) 24 2.2. The use of heroin and its alternatives 32 2.3. Starting and length of injection use 33

3. Types of risks with PAS use 36 3.1. Overdose 36 3.2. Places of use 37 3.3. Mobility of IDU 37 3.4. Frequency of injection use 39 3.5. Using shared injecting instruments 43 3.6. Time in prison 46 3.7. Patterns of risky sexual behaviour with IDU 47

4. Evaluation of risks and the place of harm reduction programmes 50

3 4 Introduction

With the falling apart of the model of Bulgarian organizations implement harm total police control and the liberalization reduction programmes among the IDU of Bulgaria's economy in the early 90- in the four cities since years 1999 - 2000. ies, heroin becomes commodity easily They implement an outreach approach accessible. This is highly facilitated by to the IDUs providing needles and the country's location on the main road syringes for exchange, as well as health of heroin from Turkey to Western services. As a result from this experi- Europe. Unlike Central European coun- ence the programmes were able to tries such as Hungary, the Czech secure a unique possibility to interview a Republic and Poland, however, Bulgaria great number of not easily approachable has been a much more isolated country persons (from hidden and encapsulated during the time of Soviet domination and communities) who were to provide the heroin epidemic in the middle of the answers to questions that are not easy 90-ies turned into a virtual cultural shock. to talk about. At the same time the country's encapsu- The survey team hopes that after this lation has preserved the conservative survey it will be much more difficult to attitudes of the population, which is make incompetent statements, now that extremely hostile to drug users. As a facts are available. result, the injection drug users in the country's largest cities become hermetic and marginalized groups. Regrettably, despite the epidemic rate of growing use of psychoactive substances after 1990, the public continues to know too little about the drug users, as well as about the risks related to them. The project ,,From Pilot to Professional’’, funded under the EU PHARE programme made possible the conduction of the first national survey among out of treatment injection drug users (IDU) in the country. In the summer of 2003 four Bulgarian non-government organizations - Initiative for Health Foundation - Sofia, Dose of Love Association - Bourgas, Panacea Foundation - Plovdiv, and Pleven 21 Century Foundation in cooperation with the Addiction Research Institute IVO - Rotterdam succeeded in conducting a survey requiring special efforts. The four

5 6 Design, methodology and background of the survey

The survey ,,Injecting drug users in in 18 sections, to be covered in 45 min aver- Bulgaria - profile and risks’’ is to meet age length of an interview. several principal aims: The questionnaire was prepared as ! To gain an overall idea of the demo- based on models used on many occasions graphic and socio-economic profile of by the Dutch partners in research projects the country's injecting drug users; of the Addiction Research Institute IVO, ! To attain a clear picture of the immediate Rotterdam. The final version was the out- environment where the drug users live come of a working seminar, attended by (housing, family, frequency of environ- four Bulgarian teams of sociologists - each ment change, etc.); representing one of the Bulgarian non-gov- ! To analyze the existing patterns of drug ernment organizations carrying out the proj- use with regard to the types of psychoac- ect - Initiative for Health Foundation - Sofia, tive substances, frequency of use, man- Dose of Love Association - Bourgas, ner of use, crises during use, etc. Panacea Foundation - Plovdiv, and Pleven ! To analyze the patterns of access to 21 Century Foundation, as well as by drugs; experts of the Dutch partners in the face of ! To describe and analyze the patterns of Cas Barendregt and Agnes van der Poel. risk-posing social behaviour among drug Before the launch of the survey the ques- users; tionnaire was tested in a pilot study of 10 ! To describe and analyze problems faced IDU, and was additionally modified accord- by drug users - difficulties with parents, ingly. law enforcement and access to health A total of 501 IDU were interviewed during care; the interval 28 July - 7 October 2003. ! To explore the main risk factors enhanc- Selection of participants took place in 4 ing the chances for HIV and blood-trans cities according to preliminary quotas deter- mitted infections, along with certain work- mined. 201 interviews took place in Sofia, able alternatives to change the present 100 ones in each Plovdiv and Pleven, and 99 status quo; in Bourgas. The basis for IDU recruitment ! To compare the risk levels among injec- were attendants of the needles and tion drug users (IDU) covered by harm syringes exchange programmes (NEP) of reduction programmes to those with IDU Initiative for Health Foundation in Sofia, of outside of the programmes. To verify the Panacea Foundation in Plovdiv, of Dose of hypothesis that participants on harm Love Association in Bourgas and of Pleven reduction programmes have lower risk 21 century Foundation in Pleven. The quo- behaviour as related to HIV and blood- tas for each of the cities were divided into transmitted infections thanks to having two groups: “participants’’ (“attendants’’) better health care culture and awareness on NEP and “non-participants’’ (“non-atten- of the risks related to injecting and dants’’). Interviewee selection followed the unsafe sex. principle of keeping anonymity, for recruit- As method of collecting information what ing NEP participants their personal anony- was implemented was benchmark interview mous codes were used through which they with respondents (face-to-face). The ques- take part in the programmes. For each of tionnaire contained 261 variables grouped the four programmes a step was chosen to

7 fill the “participants’’ group, observing the it turned out impossible to trace the person principle that must have been NEP atten- behind the respective code, even with the dants for six months before the survey. With close cooperation of the outreach workers. the “non-participants’’ the method used was (2) A large number of the programme atten- "snowball’’ by one step. Each of those dants use false codes (and frequently selected as interviewees gives the names of change them), which renders their identifi- several non-attendants (between 2 and 6) cation impossible. (3) The small number of and the interviewers randomly choose one. stable NEP attendants at the outreach Each respondent was paid 5 BGN for an points was selected for the survey, which interview and 3 BGN for a ,,non-attendant’’ was additionally reduced, especially among they have brought. The initially intended IDU ethnic Roma (a considerable number of proportion between “attendants’’ and “non- attendants were in prison at the time of the attendants’’ was 75% to 25%. survey). (4) The seasonal specificity at the External factors in the process of the sur- time of conducting the interviews - a signifi- vey necessitated certain changes of the cant number of IDU were outside of Sofia at original plan. In Pleven out of 76 regular the time, which largely complicated the attendants six months before the survey 62 process of recruitment of both ,,regular were reached - the rest happened to be out attendants’’, and ,,non-attendants’’. of town for the summer season or due to Supplementary to the benchmark inter- police custody. As a result, the non-atten- view, information was collected in the form dants are 38 instead of 25 planned. In of participant observation. This observation Bourgas the correlation “attendants’’ - “non- involved our staff taking notes about the attendants’’ is 51 to 49, the main reason for interview process, the more relevant events the change being the fact that in the vaca- and issues discussed with IDU, registered tion city the number of non-resident IDU as taking place in their natural environment. seasonally increases times the usual, while This information was taken down in a record the regular attendants scatter around the book to be later analyzed for the purpose of seaside and cannot be reached. In Plovdiv supplementing and elucidating the data col- the correlation “attendants’’ -,,non-atten- lected by the questionnaire, thus securing dants’’ is 82 to 18. The setting up of new the external validity of the quantitative data. points for exchange of needles and syringes in Plovdiv was why the principle was opted for the new NEP attendants there to be interpreted as “non-attendants’’. In Sofia “the NEP attendants’’ are 128, and “the non-attendants’’ - 72. In the capital city towards the end of the inquiry all traced NEP attendants had to be interviewed, and among them ,,key’’ ones were employed to bring in 4-5 non-participants in the programme. The reasons why the approach was thus altered are the following: (1) The registration codes initially used to compile the randomized sample proved not sufficiently reliable. In fifty percent of the cases

8 1. Demographic and socio-economic profile of the injection drug users

1.1. Demographic characteristics

Using the survey data, it should be tries and the Central-European ones (see borne in mind that, unlike typical repre- Table 1). sentative studies, in this case we have Table 1. IDU by country and by gender (%) results from two types of quotas1, which implies that all characteristics suggested Men Women below do not claim to be representative. Sweden 64 36 Yet, the data obtained are unique and Austria 72 28 there is enough evidence to presume that Finland 73 27 Denmark 77 23 the demographic correlations acquired do Ireland 77 23 reflect the real demographic structure of Germany 80 20 the drug users' population in Bulgaria2. France 80 20 A starting point for the analysis can be Holland 80 20 Bulgaria 80 20 the distribution by gender. Data confirmed Portugal 83 17 the correlation men-women attained under Spain 85 15 previous studies, medical statistics and Greece 86 15 expert estimations. The ratio is nearly 4:1 in Italy 87 13 favour of the men (see Chart 1). Source: ÅMCDDA, Annual report 2003 Comparing Bulgaria with Western- http://annualreport.emcdda.eu.int/en/page109-en.html European countries, we can see the country is naturally positioned right as a borderline Notably, cities appear to come divided case between the South-European coun- into two groups: in the largest cities - Sofia and Plovdiv the correlation is 3:1, and in Chart 1. Distribution by gender cities like Bourgas and Pleven - 7:1 (see Chart 2). The most powerful factor causing this dichotomy among cities can be said to be the participation of the Roma population. As it has been mentioned, the presence of Roma among the IDU in Pleven and Bourgas constitutes single individual cases. A comparison of the Bulgarian and Roma populations by gender demon- strates that with the Roma the female proportion is considerably larger than with the Bulgarians (see Chart 3 and the analysis by ethnic presence). N=501

1 By cities, and by the indicator participant-non-participant in the needles and syringes exchange programmes. In this context all demographics obtained are within the set quotas and give some very general structure, not claiming to reflect the demographics of neither the country, nor even the cities where the inquiries were held. 2 Due to the large number of cases and the possibility to compare different types of cities.

9 On the other hand, worth not- Chart 2. Distribution by cities and by gender ing is another factor. According to the survey data, the inclination to deviant behaviour among the women is more conspicuous in larger cities as compared to the smaller ones, and among the Bulgarian ethnic group (see Table 2). With regard to the participation/non-participation in needles and syringes exchange programmes (NEP) another interesting regularity is observable -- more women's presence (Chart 4), which can be interpreted in the sense that N=501 the participants are more inclined to more risk behaviour (a hypoth- Chart 3. Distribution by ethnic groups and by gender esis discussed later in the text). Analysis by age shows that the youngest respondent is 15 years old3, and the oldest - 52 years of age. According to data, the average drug users' age is 24,2; 23,0 if median is used (see Chart 5). Observably 81% of the drug users fall within the range 18-28 years of age, 69,8% belonging in the group below 25. These data, along with the answers to the N=501 question, ,,What age were you

Table 2. Comparison of IDU by ethnic group and Grouping of IDU by age gives the following gender picture:

Roma Bulgarians Age groups Percentages Plovdiv Men 68,8 % 75,4 % Under 20 17,2 % Women 31,2 % 24,6 % 20-25 45,3 % 25-30 24,6 % Sofia Men 71,4 % 76,8 % 30-35 10,6 % Women 28,6 % 23,2 % over 35 2,4 % N=301

3 Importantly, given the condition NEP do not work with youths aged under 18, a ,,natural’’ barrier existed in the sample range of programme ,,attendants’’, and nobody under 18 fell in. Along these lines the fact can be explained, that with the ,,non-attendant’’ group the average age was lower.

10 Chart 4. Juxtaposition of attendants - non-atten- As in regard to the NEP non-partici- dants by gender (%) pants, however, the hypothesis that the average age is lower was justified. The average age of the NEP participants is 25,1 while that of the non-participants is 22,0 . When the age of IDU is analyzed, extremely important is the question what the trend is like concerning the average age. Worldwide practice has demonstrated that lowering of the average age creates preconditions to expect growth of use and its related risks. The survey data, however, shows N=501 that the trend is towards growing average age among IDU. If we com- when you first injected illicit drugs?’’ give us pare with the survey5 of Initiative for Health grounds to assume that the most risk of 1998, a visible shift of the IDU average exposed age zone is 17-21 years of age. age is seen - from 21,5 to 26 years of age. As to the average age by gender it turned What is more, if then more than 3/4 of the out there was almost full coincidence respondents were under 25 years of age, between men and women, which can be now 60% remain within this age range. described as surprising. Another unexpect- Regrettably the 1998 survey was not repre- ed specificity of the distribution by age is sentative and took place solely in Sofia. the higher average age for the Roma ethnic These data get confirmed by the registra- group, respectively 25,5 (Median - 24,0). tions of NEP attendants6 and the operative Distributions by age for the four cities police statistics on the average age of users showed that the highest is the average age in custody. in Sofia -25,0 . In the remaining three cities Similar trend, however much less con- the average ages are very close to one spicuous, is observable with IDU looking for another: in Plovdiv -22,0, Bourgas - 22,8 assistance at the National Centre for and Pleven - 23,6 years of age. Lower Addictions (NCA) (see Chart 6). average age in cities like Plovdiv and Lower average age is explicable in many Bourgas is caused by the fact that the old- ways. In the first place the country's demo- est IDU there is 35, while in Sofia - 52, and graphic factors are at play. Low birth rates the IDU over 40 years of age are 5% of the in the mid-80-ies gave less numerous respondents. Lower average age in the cohorts7 entering vulnerability age zone (15- cities outside the capital is explicable in 18 years of age) after 2000 than those in terms of existence of users in Sofia as early 1995-1999. Secondly, clear indications are as before 1990, as well the earlier beginning there, that the peak of the heroin epidemic of the ,,heroin epidemic’’4. has passed in 2000-2001 and the trend is

4 See “The Drug Market in Bulgaria’’, Center for Study of the Democracy, Sofia 2003 ã. 5 ,,Injection drug use: situation, trends and risks’’, ,,Initiative for health’’ Foundation, Sofia 1998. 6 According to demographic data contained in the registration files of programmes attendants in the four cities. 7 Those born in the same year.

11 Chart 5. Age distribution of IDU.

N=501

Chart 6. Average age of first use and looking for treatment (%)

Source: NCA now slightly downward8. To the above two new, ,,fashionable’’ narcotic substances factors we can add the introduction and (various versions of amphetamines and establishment among these age groups of cannabis).

8 Various factors have contributed to the end of the heroin epidemic. Firstly, the public experience accumulated, hence recog- nition of the danger on the part of the generation of adolescents in the 90-ies. Crisis in the structure of drug distribution bringing about a drop in the quality of offered heroin, etc.

12 Chart 7. Average age of those seeking help for the in the country will continue to grow, first time (%) and that the harm reduction programmes for IDU will have to take into account that the IDU population will be growing older. Along ethnicity lines the survey shows that the two groups of IDU are Bulgarians and Roma, representing 95,6% of the sample (see Chart 8). Interpreting the data one should consider big differences between the four cities where the survey took place. Residents in Sofia and Plovdiv are a significant number of representatives of the Roma ethnic group who are seriously affected by the epidemic of injection drug use and the study has registered this saturation (see Table 3). In Bourgas and Pleven there is a special ethnic situation. In Pleven Roma ethnic group is very small, while in Bourgas - although there is a Chart 8. Ethnicity distribution sizeable Roma ethnic community, as per reports of the NEP working in the city, practically there are no IDU among them. The Turkish ethnic group also has its presence in three of the cities, still reasons are there to believe that in the cases of Sofia and Plovdiv it is the Roma who have Turkish self- identification. However, no clear explanation suggests itself for Pleven, where in percentage expression the share of IDU from the Turkish ethnic group is significant. The survey data have manifested, that

N=501 among the Roma ethnic group injection use in Sofia and Plovdiv is 3 to 7 times more in The comparison of the average age of comparison with the Bulgarian. According Bulgarian IDU with that in the countries of to available demographic data and estima- Western Europe (see Chart 7) shows that tions the Roma population in the capital city Bulgaria is a “very young’’ 9 country as yet. is between 3,5% and 4,5%, and according Along these lines it can be prognosticated, to the survey the Roma IDU in Sofia are that probably in the future the average age 28%. In Plovdiv the Roma ethnic group is

9 The sole data allowing us to draw a valid parallel of the average age of IDU in Bulgaria with those in Western Europe are the data on those seeking help for the first time. Here it must be said that NCA average age data for the period 1998-2000 come very close to the data of Initiative for Health Foundation, and seem a relatively sound basis for comparison.

13 Table 3. IDU comparison by ethnic groups in the four and in the last 4 years the registered per- cities (%) centage growth is double digits. This influx of foreigners is further substantiated by emi- Sofia Plovdiv Bourgas Pleven Bulgarian 68,7 61,0 98,0 92,0 grant channels from Asia and Africa pass- Roma 27,9 32,0 1,0 1,0 ing through the country. In view of this Turkish 2,0 3,0 0,0 7,0 human traffic, the typical practice for the Armenian 0,0 1,0 0,0 0,0 transit travellers is to remain in the country Other 1,5 3,0 1,0 0,0 longer. All this gives rise to assumptions, N=501 that foreigners are a risk factor in the injection drug use. The survey registered 0,8% assessed to be within 8% to 10% of the (n=4) foreign presence in the sample, city's population10, and the Roma among which matches the percentage of foreigners IDU are 32,0%. permanently residing in Bulgaria11. The NEP “attendants’’ and “non-atten- Unfortunately, though, the small number of dants’’ data is relevant to analyze only for cases does not allow making any valid esti- Sofia due to the insufficient number of “non- mation as to whether actually the risk-bear- attendants’’ in Plovdiv. In the capital city the ing foreigners have been reached by NEP. Roma predominate among “the atten- A cross-section manifests that three identi- dants’’- 40,2%, while in the group of non- fied themselves as “attendants’’, while one - attendants they represent as little as 9,7% as “non-attendant’’. Notably, according to (i.e. the Roma are 4 times more among the experts, among the foreigners coming from attendants in comparison to non-atten- the Middle East there are a significant num- dants). ber of IDU, yet they are a “hermetic’’ com- Important is the issue of what the situa- munity, and remain therefore difficult to tion is with the injection drug use among the reach by NEP. foreigners residing in Bulgaria. It is well- Distributions by education show, that known that in the country after year 1990 a more than half (53,4%) of the IDU have sec- serious growth is observable of “the new ondary education and a relatively small per- minorities’’, that is persons settling in centage (8,4 %) have no education or have Bulgaria coming mainly from the Middle a university degree: (4,2% see Table 4). East, China and less frequently from North The juxtaposition of the IDU education Africa. According to various analysts, it is structure with the country's education struc- through these emigrants from the Middle ture shows greatest discrepancy with the East that heroin started to invade Bulgaria group of college and university degree hold- in 1990. On the other hand, the country ers, where the average percentage for the boasts a traditionally strong tourist industry country is higher. Also with the IDU the per- welcoming over 3,5 million tourists annually, centage of those below basic education is

10 It must be said that researchers in Bulgaria debate at present on the size of the Roma ethnic group. According to 2001 census, the Roma population totals 370 908 (4,7% of the country's population). This figure is believed to be low due to the fact, that part of the Roma population is self-identified as Turkish, and to a lesser degree - as Bulgarian. As a result, the evaluations of the size of the Roma community range between 400 and 800 thousand. Similarly stand the evaluations by settlements. Sofia is believed that out of a population of 1 170 842 (2001) between 35 and 45 thousand are Roma, for Plovdiv - out of 375 000 - between 30 and 40 thousand. Factors additionally contributing to some fuzziness of the evaluations relate to the huge migration of the Roma population - both constant and seasonal. 11 According to expert evaluations the foreigners permanently residing in Bulgaria are 1% (standing for around 62 thousand) of the country's adult population.

14 Table 4. Distribution by education (%) IDU Average for IDU “non- Roma IDU the country attendants" No education 8,4 9,0 6,9 43,3 Primary school (4-th class) 5,6 3,5 22,2 Basic school (8-th class) 27,2 27,2 24,8 25,6 secondary (11-12-th class) 53,4 50,0 57,9 7,8 college (+ two years) 1,0 4,8 1,0 bachelor (+ 4 years) 2,6 12,0 4,0 1,1 master (+ 2 years) 1,6 1,5 other ,2 0,5 N=501

Table 5. Comparison of IDU education by cities

Bourgas Pleven Plovdiv Sofia No education ,0% ,0% 15,0% 13,4% Primary school (4-th class) 1,0% 1,0% 8,0% 9,0% Basic school (8-th class) 23,5% 32,0% 34,0% 22,9% Secondary (11-12-th class) 68,4% 61,0% 40,0% 49,3% College (+ two years) ,0% 2,0% ,0% 1,5% Bachelor (+ 4 years) 5,1% 1,0% 3,0% 2,0% Master (+ 2 years) 1,0% 3,0% ,0% 2,0% Other 1,0% ,0% ,0% ,0% N=501 higher, still with the remaining primary edu- With regard to the distribution by settle- cational degrees there are no significant dif- ments, strikingly enough, the largest cities ferences. Commenting on the IDU level of Sofia and Plovdiv are the place of residence education, it must be borne in mind, that of the most of those with no education and their average age in the country is still low primary education (see Table 5). 23-24 (especially outside of Sofia), and with Juxtaposition by ethnicity principle gives a its anticipated movement up, it can be pre- clear clue to this seeming anomaly - over dicted that the educational levels will also 91% of the Roma have education basic or go up. The comparison “attendants’’ ver- below basic. Thus in the cities where the sus “non-attendants’’ shows, that the “non- Roma ethnic group is well-represented attendants’’ have higher level of education among the IDU, the educational structure (see Table 4). reflects that.

15 1.2. Socio-economic profile

Outlining the socio-economic profile time, it becomes clear that there is a really three major IDU characteristics will be impressive “diversification’’ of sources. considered - incomes, family environ- Out of 15 pointed to in the inquiry, only 5 of ment and housing conditions. the sources yielded less than 8%. When One of the least clear questions related interviewees were asked to determine to drug use in Bulgaria remains to be how which is the most important source for this use is possibly funded in view of the them, “first’’ and “second’’ places were country's utterly low average incomes. again “parents’’ and “employment without Present survey data for the first time in our contract’’. Defining the sources in this way country allows an analysis of the main we are able to see that there are two sources of incomes and “personal strate- almost equal groups, with various person- gies’’ among this isolated and hermetic al strategies to earn income (see Table 7). group - the injection drug users. According A more numerous group - 38% of the IDU to the inquiry on the personal strategies, depend on their parents first, then on some typically they have access to more than other source. The second largest group of two sources of income on average (see 32% puts first a source of incomes differ- Table 6). ent from parents (relatives) like employment without contract, thefts (no violence), Table 6. Rating of IDU sources of incomes selling sex services etc. enlisted. The cross-analysis shows, that 85,4% from % those supported by their parents also live From parents / relatives 75,8 Other legal employment, "grey", no contract 43,3 together with them. How very significant Crimes against property: thefts 38,7 parent support is comes substantiated by Other 26,6 the fact, that even when relationships with Legal employment, "white" employment, their parents are poor, 64,3% continue to under contract 19,8 receive support. Dealing in illicit drugs (for their own account) 13,6 Employment for a dealer as shipping, The attempt to describe any strategies racketeering, intermediating, dealing, etc. 11,8 different from these two where the parents Begging 11,2 are the pillar, demonstrated that over fac- Crimes, involving violence torial analysis12 of 15 sources of incomes, (burglary, assault, blackmail, etc.) 8,0 Selling sex services (for themselves) 8,0 several alternative patterns shape them- Rents 6,2 selves. The first factor, which we provi- Social benefits 4,6 sionally call “crime activity’’, shows a high Selling sex services (through others) 3,6 positive correlation value with such Dealing in medical drugs or methadone 3,4 sources of incomes as “crimes against Scholarship 2,4 N=501 property’’, ,,crimes using violence’’, ,,employment for drug-dealer’’ or “as drug- As seen, 75% of the IDU depend on dealer’’ and negative feelings for incomes means from their parents (relatives), sec- from “parents’’ and “incomes from ond to which comes employment without employment’’. Such “anti-parent’’ scheme contract, and third - thefts. At the same is also found with the two factors where

12 Statistical analysis outlines 6 significant factors

16 Table 7. Rating of sources of incomes for IDU (%) First in Second in importance importance Parents 37,7 32,4 Other legal employment, "grey", no contract 15,4 16,7 Crimes against property: thefts 11,6 14,1 Other 7,0 13,8 Selling sex services (for themselves) 5,0 1,2 Dealing in illicit drugs (for their own account) 3,0 1,9 Selling sex services (through others) 1,6 0,7 Rents 1,4 2,3 Employment for a dealer as shipping, racketeering, intermediary, dealer, etc. 1,2 3,3 Begging 1,0 2,8 Social benefits 0,8 1,4 Crimes, involving violence(burglary, assault, blackmail etc.) 0,6 2,3 Dealing in medical drugs or methadone 0,4 0,7 Scholarship 0,7 N=501

Table 8. Comparison by factors

Crime Selling sex Selling sex services (1) services (2) From parents -0,174 From parents -0,525 Legal employment under contract -0,251 Legal employment under contract -0,393 Crimes against property 0,696 Social benefits 0,524 Crimes, involving violence 0,502 Crimes, involving violence -0,360 Selling sex services (for themselves) 0,535 0,549 Selling sex services (via somebody else) 0,173 -0,572 Drug dealer (working for other) 0,658 Drug dealer (working for other) -0,288 0,212 Drug dealer (for their own account) 0,673 Drug dealer (for their own account) -0,318 0,232 Begging 0,373 N=501 income from selling sex services is high- spending in Bourgas and Sofia might in est (see Table 8). reality go significantly up due to poli- Income sources data serve as good use infiltration, as compared to Plovdiv grounds to draw several central conclu- for instance (see Part 2). Juxtaposing sions: these figures it must be borne in mind ! Based on the average frequency of that at the time of survey the average heroin use (see Table 25) and price per salary in Bulgaria was 280 leva, while dose13 the approximate average month- the average per capita income was ly IDU spending on heroin could be ten- around 130 leva. Hence, the only possi- tatively calculated. That is lowest in ble strategy for the IDU can be none Pleven - between 38 and 45 leva, mov- other than looking for different sources ing up to 115 - 174 leva in Bourgas, of simultaneous incomes. reaching 180 - 260 leva in Sofia to go ! Primary source of funding for drug highest in Plovdiv between 205 and 480 use undoubtedly are the parents. The leva. It is noteworthy that the IDU argument, IDU explain their parents'

13 During the summer of 2003 a dose of heroin cost an average of 6 leva in Sofia, 5 leva in Bourgas and Plovdiv, and in Pleven - 3 leva.

17 behaviour here is, that ,,My parents public services (administrative, health care, give me money since they consider that education, etc.) In the four cities, where the better than me going out stealing it’’14. survey was held, the percentage of IDU with- The factorial analysis shows, that the out identification papers varies, and respec- alternative behaviour really is crime tively the NEP “attendants’’ can be consid- proper (violence or no violence), selling ered as exposed to a different degree of risk. sex services, drug dealing and beg- Largest is the number of persons without ging. Discussing the role played by the identification in Plovdiv - 36%, followed by parents in IDU behaviours, it must be Sofia - 25%, then Pleven - 11%, and Bourgas taken into account that, due to cultural - 12%. Again the main factor to increase the specificity, the preservation of the fami- risk here are the Roma. While with the ly as a source of income also gives Bulgarian and the Turkish ethnic group 15% them a chance to evade isolation and and 14% respectively have no identification marginalization. Notably, this cultural documents, among the Roma they are more tradition exerts influence on refraining than half - 51%. from extreme behaviour (participation As it has become clear that the incomes of in crime groups, use of violence, IDU are strongly dependent on the parents, vagrancy, etc.). the question arises what is the family environ- ! Evidentially, some 80% of the IDU do ment where they live. How far is the hypothe- not make social and health security sis justifiable, that the deviant behaviour has contributions. The reason is that they led to the isolation of the drug users from their do not have normal labour contracts. families? The present survey data reject Even those who work, usually do so such an assumption and demonstrate, that being employed in the grey economy. 60% of the IDU continue to live with their Numbers vary in different cities. The sit- parents (see Chart 9). uation is harshest in Plovdiv where only Cohabitation with parents has its both 8% have contract employment, in economic and cultural roots. It is very hard Pleven so have 14%, in Sofia - 18%, and for the “kids’’ to leave their family due to in Bourgas - 41%15. The contract high housing prices, thus the co-habitation employment difference is in favour of of two, even three generations is common the “non-attendants’’, who are 24%, in Bulgaria. On the other hand, the living while with “the attendants’’ it is 17%. together with parents, and grand parents The survey registered, that nearly 22% (5%) secures easier support (financial, do not have identification documents. This social, etc.) fact, along with the estimated 80% having Analysis by cities shows, that relevant dif- problems with their health and social insur- ferences exist, the family cohabitation model ance, creates conditions for further social being most visibly “impaired’’ in Sofia (as isolation. People with no personal identifica- could have been expected) with nearly half tion have difficult access to nearly all types of of the IDU living separately from their par-

14 See for more detail the field observations data collected in the course of the interview field work. Such descriptions can be found for instance Atanas Rusev in his analysis of the drug use in Sofia (Rusev, Atanas; Injecting Drug Users in Sofia, Sofia 2004, Initiative for Health Foundation). 15 It can be assumed that the NEP ,,non-participants’’ are the ones mainly contributing to the high ,,white employment’’ in Bourgas. The ,,non-participant’’ interviewees were probably holiday makers in the city, which implies better financial means corre- lating with legal employment.

18 Chart 9. Social situation in the last six months so with the Roma - 50,0%. The cross-section by ethnic principle gives the greatest percentage of Roma living as a separate family. The Roma sub- group displays more substantial differences with the Bulgarians, the Roma observably more frequently have a family with kids - if among the Bulgarian IDU the percentage of family people with kids is 3,9%, among the Roma this percentage is more than four times higher: 16,7%. With

N=501 them, too, the share of single parents with kids: 2,2% to 0,5% -- is different. These are facts easily explicable in view of the cultur- ents (see Table 9). Regrettably there is no al specifics of the Roma ethnic group, research to help evaluate how far the drug where marriage (and early marriage at that) use affects the social situation, and how far is a social norm. “the destruction’’ of the cohabitation pattern Considering the social situation by gender has been resultant from the social and eco- we had to face a surprise - it turned out the nomic changes in recent years. women have visibly stronger “anti-traditional- Possibility for comparison of the IDU social ist’’ behaviour as against the men - only situation over time gives the survey conduct- 43,5% live with their parents, while 22,8% live ed by Initiative for Health in Sofia of 1998. This with their sexual partners (see Table 10). survey has found out that Table 9. Comparison of social situation by cities (%) then 2/3 of its respondents lived with their parents as Bourgas Pleven Plovdiv Sofia against 51,7% at present. on their own/single 9,1 20,0 6,0 15,9 The patterns of “living without with an intimate partner 6,1 9,0 8,0 10,0 with partner and kid/kids 3,0 2,0 9,0 8,5 parents’’ have visibly with kid/kids (no partner) 2,0 0,0 0,0 1,0 become more. The changes with parents 69,7 59,0 68,0 51,7 are most significant with with another family 1,0 3,0 5,0 8,0 those who live on their own - with others 7,1 5,0 4,0 4,5 they total nearly three times other 2,0 2,0 0,0 0,5 N=501 more now -15,9% against 4% in the 1998 survey. Figures Table 10. Comparison of social situation by gender (%) with regard to those living Men Women “Attendant’’ “Non-attendant’’ with a partner generally coin- of NEP of NEP cide - 11% in 1998 versus on their own/single 13,8 11,9 10,8 15,1 10% in the present study. with intimate partner 5,0 22,8 7,4 9,4 The pattern of cohabitation with partner and kid/kids 5,8 7,9 1,0 9,7 with kid/kids (no partner) 0,5 2,0 0,5 1,0 with parents is most common with parents 64,4 43,5 69,0 54,0 with the Turkish ethnic group with another family 4,5 6,9 4,4 5,1 - 71,4%, then with the with others 5,0 5,0 5,4 4,7 Bulgarians - 61,7%, and least other 1,0 0,0 1,5 1,0 N=501

19 Among the men only 5% live with their part- homeless category (virtually homeless, ner and 64,4% with their parents. It is not too). However the share of homeless IDU is clear here what the effect is of the Bulgarian relatively small, it remains unclear whether cultural tradition, according to which the girl NEP manage to reach out to this highly risky is to live with the boy's parents. In the corre- group due to the fact that the homeless fall lation “attendants’’- “non-attendants’’ of within the utterly marginalized and hermetic NEP, “the attendants’’ have displayed visibly social groups. The analysis of Sofianep IDU more conservative behaviour. shows, that there is a group (3,5%), and The substantial share of those living with mainly of Roma origin, who live in municipal their parents is predetermined by the housing facilities. In view of the poorest Bulgarian cultural specificity that the aver- condition of these hostels, it might be fair to age family in cities has their own place to refer them to the category of those living in live, and that explains why only with 9% of abandoned houses. Going deeper into the those living with their parents do not have category “other’’ and “strongly variable’’ an apartment. (see Table 11). including a significant percentage of IDU Comparing the housing conditions (7,2%), it became clear, that whoever falls among the 4 cities, notably those living in here live in the homes of relatives or friends, their own places in Sofia are fewest, and these being variants occurring more among those renting a place to live are the most the Bulgarians, than among the other eth- numerous. This is explicable in terms of the nicities. fact that in the capital city the housing As data made evident, living together prices are the highest. On the other hand, with their parents, and in the houses of their the fact that the “cohabitation with parents’’ parents, respectively, refutes the hypothesis pattern is weakest in Sofia leads to looking that IDU are isolated from their family envi- for housing alternative to the parents' hous- ronment. Another assumption indirectly ing with 45,8%. denied is the one about “the nomadic way The survey shows, that 94,4% of the IDU of living’’ of the drug users. A specifically live in the four surveyed cities, another 4,6% targeted block of questions dealing with - in municipalities close to the cities, and 1% IDU migration casts light on the fact that describe themselves as homeless, all of nearly 60% of them have not changed their whom are from Sofia. According to the field place of residence for more than five years. observation, these mainly live in the area of Some 22 --23% of the sample can be the Central Railway Station. The 1% living in described as the most mobile. They have abandoned houses must be added to the changed their place of residence in the

Table 11. Comparison of housing conditions (%)

Lives in (%): Bourgas Pleven Plovdiv Sofia Average for the 4 cities Their own apartment 36,4 30,0 21,0 15,4 23,6 Lease apartment 5,1 3,0 7,0 14,9 9,0 Abandoned house 2,0 1,5 1,0 Hostel 1,0 3,5 1,6 Parents' apartment 53,5 58,0 67,0 54,2 57,5 Very different 2,0 3,0 4,0 2,6 Other 3,0 8,0 6,5 4,8 N=501

20 last year, with about half of them having residence against 14,4% with the Roma. done that in the past 3 months. These results are surprising and contradict Therefore, the conclusion may be drawn the findings of various surveys of the Roma that in the country there is a sizeable and ethnic group giving evidence of consider- very mobile group of IDU that can be able Roma migration from small settlements described as risky, and is to be followed to the largest cities (especially to Sofia)16. In closely by NEP. this context it must be said that probably Comparison by ethnic groups exposes with the Roma IDU the explanation is eco- the Roma as a little bit more mobile than the nomic more than it is cultural. It is likely that Bulgarians. The Bulgarians have lived at the probably the Roma in the sample have been same place for 135 months (11,3 years) on victims of the “heroin epidemic’’ in the late average, versus 131 (10,9 years) months 90-ies, hence they are economically with the Roma. This approach of finding an trapped within their neighbourhoods. These average value, however, seems much too data yet pose the question whether the new formal, and if the most mobile parts of both Roma migrants coming from small cities ethnic groups are subject to comparison, have withstood drug use, or they are isolat- the reverse situation will be observed. ed and the NEP have not managed to reach During the last 12 months 24,7% of the out as far as them. Bulgarian IDU have changed their place of

16 The main reason for this migration in the first years after 1990 was looking for cities where social benefits are regularly paid and some legal or illegal income can be found. Most attractive here are the largest cities - Sofia, Plovdiv, Varna and Bourgas.

21 1.3. Contacts with public institutions

The survey attempted to depict and ana- Apart from detentions, as per the survey, lyze the relationships between IDU and two the contacts with the police are unusually types of institutions they are most depend- frequent - 68,3% have had their papers ent on - the law enforcement and health checked in the last six months, while 53,1% care. have been searched. Violence on the part of The survey findings demonstrated that the police has been reported by 2% of sur- a significant portion of the incomes of the vey respondents, and unlawful activities like drug users depends highly on illegal seizure of syringes and needles - 15,6%. sources such as selling drugs, employ- The distribution by cities shows, that the ment for a drug dealer, thefts, crimes percentage of detentions is highest in involving violence, procuring, selling sex Plovdiv - 40,0% of all IDU, followed by services, begging and so on (see Table 6). Bourgas with 32,8%, Sofia - 34,3% and These sources of incomes are reported by Pleven - 28.0%. An unexpected finding was over 50% of the IDU. It is also noteworthy that IDU of the Bulgarian ethnic group get that the very possession of illicit psy- detained more often than the Roma - 35,2% choactive substances is also grounds to against 34,4%. 39,6% NEP “attendants’’ be taken in police custody17. It became have been detained, while the “non-atten- clear from the interviews that in the past dants’’ are 28,6%. As expected, the number six months 35,1% have been detained by of detentions with the men is double that of the police. The average length of deten- the women: 39,3% to 18.8%18. The distribution, as pointed by the interviewees was tion by age shows, that there is no clear 16,04 days (if recalculated as median - 2,0 tendency of older age - fewer detentions, days). It must be borne in mind that prob- like with the non- users of drugs. The data ably this long average period of 16 days is revealed, however, that with the youngest the result of 12% of those having been age group (below 20 years of age) deten- detained who mix up police custody with tions are most frequent - 43,0%. serving effective time in prison. The high riskiness associated with IDU, both from the point of view of their health, The reasons why IDU have been detained and in terms of risks for the public overall in the last six months are: (because of dangers to transmit various dis- % eases) must presumably provoke the spe- Crime against property (thefts and the like) 22,7 cial attention on the part of health care insti- Possession and dealing in illicit drugs 12,8 tutions. Unlike “access’’ to the police, Crimes, involving violence (battery, “entry’’ to health care institutions is quite burglary, murder, unpremeditated restricted - less than half of the IDU have murder, arson and other) 5,0 “health insurance’’ (see Chart 10). In view of Other crimes (vandalism, illegal arms the absence of legislative solution for the possession) 3,4 persons for some reason not having paid

17 Presumably, now that the allowable personal dose of drugs has been denied, the possibilities for detention of drug users by the police have become limitless. 18 Evidently female detention with IDU is much higher than the country's average, where the proportion is 5:1 in favour of the men.

22 Chart 10. “Have you got health insurance?’’ service IDU obviously out of what has remained of the “socialist inertia’’, or the medical doctor's moral commitment. Of those reporting that they have not been insured, 41% have visited GP or an out- patient policlinic. Only around 14% state that they have been to some degree dis- satisfied with the service. The percentage of persons without health insurance varies in the four cities - surprisingly few have been insured in Sofia - 36,8%, followed by Plovdiv - 37,0%, Pleven - 44,0 and Bourgas - 56,6%. As N=501 expected, what placed Sofia and Plovdiv first and second for lack of insurance, is their health insurance contributions, and the the Roma population. Only 20% of them estimated number of IDU between 15 and know that they have been insured - versus 25 thousand, it can be assumed that 42% 48% with the Bulgarians. Along the “atten- not health-insured drug users in the country dants’’ - “non-attendants’’ distribution account for between 8 000 and 12 000 per- again data show, that the “non- atten- sons bearing unpredictable risks. dants’’ are less risky, among whom 45,8% Despite the absence of health insur- have health insurance - versus 39,6% ance, health care institutions continue to among “the attendants’’.

23 2. Drug use, patterns, sources, mobility with IDU.

2.1. Patterns of use by psychoactive substances (PAS)

A point of departure in the analysis of PAS (see Table 12). It must be reminded, the use of psychoactive substances is that the survey is focused on IDU, and this how much they are actually used and what pattern of drug use throws light mainly on the preferences are. Ranking the sub- the heroin users, hence does not reflect the stances according to the percentage of actual infiltration and use of PAS in the those who have used them in the last country. month allows a fairly accurate relative rat- These two manners of arrangement ing (see Chart 11). underlie the forthcoming in the text analysis attempt of PAS according Chart 11. Rating of psychoactive substances as to preference levels. used in the last month (at least once during the last Heroin is the first choice per the month %) survey, as report 95,4% of interviewees, which have used it at least once in the last month. The question, ,,Which substance is your ,,first’’ or most important substance?’’ is answered by 74,9% pointing to heroin (Table 12), and as ,,a second substance’’ heroin is a choice for 17,9%. 47,2% state they use heroin every day. The average use is 20,3 days a month, 25,0 days median. 94,0% of the interviewees claim that they have used heroin injecting it. For the sake of comparison, 4% would prefer to smoke heroin, while 3,4% -- to sniff it. Yet field observations have demonstrated that non-injection use is too much of a luxury for the heroin users. Due to low quality and high N=501 price of the heroin, smoking and sniffing are exotic behaviours19. One more possibility to present the data Contrasting the four cities reveals serious below goes according to the first choice of differences (see Table 13).

19 During the inquiry high-ranking dealers were described as predominantly smoking heroin as being able to afford it. Also ref- erences to past experience when they were able ,,to afford it years ago’’.

24 Table 12. Which substance is your ,,first’’ or most BGN. (Unfortunately, the survey was unable important substance? to compare the exact content, that is, quality and quantity of an average dose in the Number Percentage of persons of the sample four cities.) heroin 375 74,9 ! The availability of alternative drugs and methadone 30 6,0 traditions in the city. Revealing in this cannabis 24 4,8 regard is Plovdiv where PAS alternatives cocaine 20 4,0 are fewest, and the Roma population, itself alcohol 11 2,2 amphetamine 8 1,6 setting the city profile, looks mainly at other 7 1,4 heroin. other opiates 6 1,2 Methadone has been placed second gluthetimid 6 1,2 next after heroin as preferred psychoactive speedball 4 0,8 substance by 6% (as first choice, see benzodiasepines 3 0,6 LSD 3 0,6 Table 11) and by 6,3% as second choice. cigarettes 2 0,4 This substance occupies a very special gluthetimid 2 0,4 place for the IDU. The contrast of 6% pref- Total 501 100 erences for methadone to the 74% for N=501 heroin cannot but give an idea of a nearly As per data absolute leader among the marginal use of methadone. If we look at cities is Plovdiv by all three indicators, while Sofia results, however, the situation the indicators are lowest in Pleven. appears virtually different. In the capital Regrettably, the information is not sufficient city heroin has 49,3% every day use, while to allow determining the factors creating methadone goes as high as 15,4%; adding those significant differences. The survey those who claim that they use it every other data and the field commentary information day, the regular users of methadone can yet outline part of those. become 43,6% of the sample. The huge dif- ! The economic situation in the city - ference registered between Sofia and the according to NIS (National Institute of other cities, where methadone users in the Statistics) data and survey data: personal last month were in Pleven - 3 %, in Plovdiv income scores for the cities position Sofia - 1,6% and in Bourgas - 1% is explicable by first, and Pleven - last, Bourgas and Plovdiv the fact, that methadone programme only standing nearly equal in-between. This is exists in Sofia20. Evidently, the presence or also validated by the prices of a heroin absence of methadone on the respective dose. In Sofia this price in the summer of town's “market’’ (regardless of whether 2003 was 6 BGN, in Plovdiv and Bourgas - 5 legally obtained or bought on the black mar- BGN, while in Pleven it could go down to 3 ket) takes powerful effects on the structure

Table 13. Comparison of heroin use in the four cities (%)

Bourgas Pleven Plovdiv Sofia Having used in the last month 98,0 94,9 100,0 92,0 Every day users 43,4 17,2 77,0 49,3 Average number of days used during the month 20,6 14,2 28,0 19,3 N=501

20 Although methadone programme in Sofia was launched as early as in 1996, until the autumn of 2003, when the Varna project started, it was the only one running.

25 of heroin use. Expectations that methadone going to get “the kick’’ felt with heroin. In programmes will be launched in 10 more this light field observations describe two large cities of the country render this pattern groups of methadone users. The first is typ- of particular interest. Along these lines it is ically comprised by the attendants of the noteworthy to mark out certain specificities methadone programme, (and) persons try- observable with interviewee drug users in ing to terminate their heroin dependence. Sofia. The first one is that the use of They have legally provided daily dose, yet methadone has given rise to crime prac- do not manage to resist “ the heroine crav- tices. Due to various reasons the legal ing’’, and regularly, or from time to time access to methadone has been restricted “treat themselves’’22 with heroin. Of all inter- exclusively to the methadone programme at viewees only some 9% participating in the the NCA. As a result, access to methadone, methadone programme declare that they at the time the survey was taking place, had have not used heroin in the last month23. The as few as some 35021. Accordingly the sur- second group are persons who are heroin vey registered, that 78,4% of the respon- users and are outside the treatment pro- dents bought methadone on the black mar- grammes. For them methadone becomes a ket. For comparison's sake, the Initiative for special type of substitute for heroin. Health survey back in 1998 had not detect- Among the reasons why they “discover’’ ed such a phenomenon, and the methadone as surrogate are: the drastic methadone programme had already had a lowering of the quality of heroin sold in Sofia history of two years. Hence, within 5 years after year 2001 and the low price of the capital city developed a “black market’’ methadone. As reported, a dose of of methadone, well-structured at that - it is methadone in the summer of 2003 was sold no coincidence that 8,5% of the respon- in the capital city for an average of around 3 dents in Sofia receive incomes from selling BGN, i.e. twice cheaper than a dose of methadone and other drugs versus none in heroin. Also notably, despite the quality of the other 3 cities. On the other hand, data heroin went down, its price still rose from 5 have demonstrated, that the black market BGN per dose in the summer of 2001 to 6 has not managed to spread nationwide, BGN in 2003. As seen by NEP, however, and even a geographically close market methadone users must also be included in such as Plovdiv has remained “unreached’’. the risk monitoring, since at least 1/3 of The second peculiarity is that the model of them are facing the same threats related to injection use of heroin gets “transferred’’ blood-transmitted diseases and HIV, just as to the use of methadone, too. The survey the IDU of other substances. gave evidence that 32,3% of the methadone The tracing of personal “replacement users inject it. The field observations uncov- strategies’’ have shown that apart from sub- ered that, despite the awareness of most stitute ¹1 - methadone - 16,6% of intervie- users regarding the risks, they still do it wees also use traditional medical opiates either out of habit, or expecting that they are such as - morphine, lydol and codeine.

21 The situation has not changed substantially as at mid-2004 - the number of attendants has grown by just 100-120, although two private programmes in Sofia and a municipal one in Varna started operation. 22 The issue of how efficient the methadone programmes are is not an area of concern for this text, and the problems related to intravenous use of a product intended for oral use will not be discussed. 23 It must be reminded here, that the respondents were recruited predominantly among heroin addicts and these data are not representative for the methadone programme in Sofia.

26 Here, too, use in the capital city is higher - of IDU used amphetamines, in the summer 20,4% against 14,0%. Probably here, too, as of 2003 they represent already 40,8%. What is with methadone, both prerequisites are at more, field observation provides evidence work - poor quality heroin and high price. that the summer of 2003 may be a turning The use of this group PAS is relatively limit- point in the amphetamine use. There are sev- ed - only 4,6% use some of the surrogates eral preconditions for that. First, over the more frequently than every other day. In interviews attitudes were observed among view of this, the hypothesis has been dis- heroin users to look for “something new’’, proved, of a fast growth of “the black mar- “something to lift you up from your pes- ket for prescriptions’’ (as has been predict- simism’’, “something to cheer you up’’, “to ed by some analysts)24. Observable with this change the colour’’, etc. This motivation was group of substitutes, yet, is a much less enhanced by the overt awareness of the ever intense injection use, which is explicable by poorer quality of the street heroin. Similar the fact that the most popular one - codeine processes of adding some other type of psy- is in use mainly orally in combination with choactive substances are observable in gluthetimid (these substances are very many WE countries and the USA. In the past rarely taken one at a time). two years combining and even substitution Amphetamines are the group of psy- of heroin by cocaine has been registered in choactive substances stirring up most inter- most of Western Europe. In a country like est in the past few years. The reason for that Bulgaria, however, the price of cocaine is too are both many expert estimations, foresee- high and the amphetamines turn out to be ing “amphetamine epidemic’’, and serious the single replacement. The second precon- reshuffles on the “drug market’’. In this light dition, is the change in the supply. The sur- it is of interest to see that the infusion of vey registered, that the street drug dealers, amphetamine among IDU is also signifi- who before 2001 offered mainly heroin, in the cant. Despite the strong focus of this group summer of 2003 already 16,7% of them also on heroin, more than 1/3 - 36,4% report, sell amphetamines. The motivation for this that they have used amphetamines in the “shift’’ is that the import of heroin (largely last month. For comparison, nationally rep- from Turkey) is facing serious troubles (the resentative surveys have demonstrated, extremely low quality of the street heroin that around 1%, or some 67 thousand in speaks of that). On the other hand Bulgaria Bulgaria (aged above 15) have tried has traditions and well-developed indus- amphetamines25. trial capacity for the manufacture of According to expert estimations “amphet- amphetamines, which so far have been amine use among IDU is a phenomenon of exported to the Middle East 27. Low quality the last 1-2 years and the proof here are the here is compensated by the quantity due to comparative data on Sofia. If in 1998 only 9% very low prices.

24 According to this hypothesis due to low control of pharmacies and doctors authorized to prescribe opiate medication, a boom is observable in the use of morphine, lydol, codeine, etc. 25 Inquiries took place in December 2002 - January 2003 and June 2003. See ,,The Drug Market in Bulgaria’’, Sofia, Center for the study of democracy. 26 See ,,Injection drug use: situation, trends and risks’’, ,,Initiative for health’’ Foundation, Sofia 1998. 27 Early back in the 80-ies Bulgaria mastered the production of captagone and managed to secure markets for its product in the Middle East. Although the production was stopped in the late 80-ies, with the advent of democracy after 1990 specialists from former state-owned enterprises start establishing cheap manufactures in small illegal facilities. By and large yet, up until 2002 the amphetamine produced is intended for the Middle East markets. See for more details ,,The Drug Market in Bulgaria’’.

27 Table 14. Comparison of amphetamine use in the four cities (%)

Bourgas Pleven Plovdiv Sofia Average Used in the last month 59,6 18,2 16,4 40,8 36,4 Every day users 4,0 0,0 0,0 3,5 2,4 Average number days used per month 4,3 0,7 0,7 3,0 2,4 ,,Does the dealer whom you bought heroin from most frequently in the last month sell amphetamines/pico?’’ 4,0 11,0 14,0 27,9 16,8

N=501 Juxtaposition of the data on the 4 cities youngest, but those with 7-8 years of expe- show, that amphetamine has not infiltrated rience are the ones looking for stuff different different settlements equally. As seen from from heroin. the table (see Table 14), in Bourgas and When analyzing amphetamine use, it is Sofia the infiltration is 2-3 times higher in noteworthy that 11,8% of the interviewees comparison to Plovdiv and Pleven. Despite declare that they have used ecstasy in the the high number of victims, as per evi- last month. Interviewers' observations have dence, the use is still low in intensity - 2,4 revealed that interviewees do not differenti- days monthly, with 5,4% possibly called ate ecstasy and amphetamines. A confirma- regular users (2,4% every day and 3% every tion of this assumption are the laboratory other). The survey registered an interesting inquiries under forensic expert opinions, paradox, the city with highest infiltration which give evidence that in 2002 not a single and highest intensity of use - Bourgas has dose of ecstasy was seized. In this context lowest supply of amphetamines on the part experts are unanimous that the use of of the heroin dealers (see last row of Table ecstasy in the country is extremely rare due 14). One possible interpretation of such a to high price and absence of domestic pro- fact is that while the distribution networks of duction. It can be speculated that the heroine and amphetamines in Sofia almost respondents, who declared that they used coincide, Bourgas may be having them ecstasy, are actually using some other apart. group of amphetamines. Redoing the data The survey also registered an unexpect- calculations adding to amphetamine users ed distribution by age. The juxtaposition those of pseudo-ecstasy, we gain a slight along the five age groups showed that growth by 4,2%. Thus the percentage of those using most amphetamines belong to amphetamine users per month in the coun- the age group 25-30, followed by the age try reaches 40,6%. group of 20-25 (see Table 15). These data Among the most important findings of uphold the hypothesis that change is the survey was the injection use of sought of the drug in use. It is not the amphetamines. Up until now it was

Table 15. Comparison by age with amphetamines use (%)

below 20 20-25 25-30 30-35 over 35 Average Used in the last month 33,3 37,7 39,7 33,3 16,7 36,4 Average number of days used per month 1,2 2,5 3,4 2,0 0,0 2,4 Regular users 4,8 5,9 6,9 2,0 0,0 5,4 N=501

28 believed that in the country there are no Cocaine is perceived by Bulgarian drug such practices. Surveys gave evidence that users as very prestigious, yet too expensive amphetamines were taken either orally as and different from heroin29, hence many pills28, or sniffed as powder in imitation of researchers in the country believe that it is the prestigious, yet unaffordable cocaine. rarely used by this group. The survey data With the IDU, however, similar to displayed that was not quite the case. methadone, it turned out that the heroin 20,5% have used cocaine in the last habits get transferred to amphetamines, too month, yet with very low intensity - 0,9% - 17,8% of interviewees injected it. have taken it every day, another 1% -- Moreover, evidence is there that no injec- every other day, or more frequently. tion use (not a single interviewee) was reg- Similar to the amphetamines and istered in Plovdiv and Pleven, while this pat- methadone, significant injection use is tern of use goes up to 42,2% in Sofia and observable with cocaine, too - 12,0% -- the 31,0% in Bourgas. main motive being that unlike the other The cross section by ethnicity discloses manners of use, the injection use secures that among Roma population amphetamine the fullest sensation (“drug is not wasted’’). use is much lower - 17,4% as against the The only available data to compare are Bulgarian ethnic group - 40,2%. The com- again on Sofia and show, that unlike the fast parison “attendants’’ - “non-attendants’’ in growth of amphetamine use, a slight move- terms of amphetamine use shows that “the ment up is visible. From 18% in 1998 to non-attendants’’ are slightly ahead - 39,6% 23,9% in 200330. against 32,2%. The comparison of the four cities does Assessing the risk of injection use with not give any statistically significant differ- amphetamines what can be enlisted are all ences (see Table 16). Similar is the situation the problems related to blood-transmitted over juxtaposition by ethnic groups and infections and HIV. Apart from those, how- “attendants’’-- “non-attendants’’. With the ever, the injection use of amphetamines Bulgarians cocaine use is 19,8% versus should urge NEP programmes to consider 18,4% with the Roma. The figure for the that this type of PAS are not meant for injec- ,,non-attendants’’ is 21,6%, while for the “the tion use (especially those offered on the attendants’’ - 19,9%. Bulgarian market). Besides causing harsh Speaking about cocaine use cannot damage to the blood vessels and eczema, overlook the simultaneous use of heroin this group of PAS leads to high risk of heart and cocaine, the so-called speedball. Data attacks and strokes when injected. reveal, that 14,1% of the interviewees have

Table 16. Comparison of cocaine use in the four cities (%)

Bourgas Pleven Plovdiv Sofia Average Used in the last month 15,3 25,0 12,0 23,9 20,5 Every day users 0,0 1,0 1,5 1,2 0,9 Average number of days used per month 0,67 1,27 0,91 1,0 1,6 N=501

28 Various forms, stamps and colours of pills are used by the addicts as orientation for the strength and quality of effect the pills are believed to secure. 29 Survey field interviews in the summer of 2003. 30 See ,,Injection drug use: situation, trends and risks’’, ,,Initiative for health’’ Foundation, Sofia 1998.

29 used this mixed form. Most probably, at up to 40% of IDU. The comparison by cities that, the infusion takes place in one injec- shows distinctive features for each of the tion. The analysis shows, that around 15% cities, but also that in some of them IDU num- of the speedball users do not normally use ber over 70% (see Table 17). Plovdiv is differ- cocaine by itself (that is cocaine always ent, where the focus on heroin takes its comes mixed with heroin). Recalculations effects on the use of cannabis. done, it became clear that some 26,9% have The juxtaposition of heroin and cannabis used cocaine during the last month (mixed use with IDU discards the hypothesis that the use included). The survey is unable to more frequent the cannabis use, the less fre- answer the question how far the assertion is quent the use of heroin. The sole exception true that the so-called speedball in Bulgaria turned out Sofia, where in reality there is sig- contains amphetamines instead of cocaine. nificant, but weak negative correlation Cannabis31 is the most popular PAS in between the use of both groups PAS, i.e. the the country (excluding the legal PAS - alco- more heroin is used, the less so is cannabis. hol and tobacco). According to nationally Comparing by ethnicity principle displays representative surveys about 1,5-2,0% of the that the use of cannabis among the Roma population in the country (that is some 100- is nearly twice lower as against that of the 130 thousand) declare that they have tried Bulgarians - 36,7% versus 65,2% -- have cannabis. Surveys among students and used cannabis in the last month (median 0,0 schoolchildren in Bulgaria's largest cities days versus 4,0 days). With the “non-atten- (Sofia, Plovdiv and Varna) show that various dants’’ the use of cannabis products is forms of cannabis have been tried by up to 71,4% against 50,9% with “the attendants’’. 40% of them. Another correlation clearly shaping itself is At the same time, among analysts and by age. The younger the IDU, the higher the users of various PAS (including heroin) belief percentage of cannabis users (see Chart 12). is wide-spread that “heroin and grass are Over dispersion analysis by number of days incompatible.’’ Data refute this opinion - substance use during the month, this tenden- among IDU cannabis ranks second as cy becomes even more conspicuous - below used by 58,7% declaring they have used it age 20 the average use is 11,43 days (medi- in the last month, out of whom 30,4% being an 6,50); with the 20-25 year-olds the average regular users (every other day or more fre- use is 9,59 days (median 3,00); with those quently). On the other hand, in view of the aged 25-30 - 8,08 (median 1,00); with the 30- fact that the average user of cannabis prod- 35-olds - average 4,45 days (median 0,00) ucts in Bulgaria uses them between 2 and 3 and over 35 the average is 3,75 days (median times a week, it can be claimed, that this 0,00). This tendency is observable in Sofia, group of regular users is even larger - going too, where the age of IDU is highest, the use

Table 17. Comparison of the use of cannabis in the four cities (%)

Bourgas Pleven Plovdiv Sofia Average Used in the last month 71,7 79,0 35,1 50,7 58,7 Every day users 23,2 20,0 3,1 11,9 14,9 Average days use per month 12,5 13,3 5,4 7,0 2,0 N=501

31 By cannabis use is meant the use of all cannabis derivatives known under various labels in Bulgaria - marijuana, hashish, grass, ganja, joint, etc.

30 Chart 12. Use of cannabis among IDU (%) of the use of heroin - most often - insomnia, high anxiety, pains, etc. The other case when there has been use of diasepam, it was over hospitalization when they had for a certain period of time to stop the use of heroin. According to the analysis focused on Sofia32 diasepam is frequently used by those on methadone treatment. The juxtaposition by cities again registers a dichotomy, the first group comprising the capital city with 29,4% and Pleven - 25,0%, and the second one - Plovdiv - N=501 16,7%, and Bourgas - 13,1%. The distributions by ethnicity principle of cannabis is more moderate than in Pleven again demonstrate the Roma as less often and Bourgas. Evidence is there that with IDU using surrogates versus the Bulgarian ethnic cannabis is more popular with the young, group - 16,9% against 24,3%. The line “atten- and many factors cause that ranging from dants’’- “non-attendants’’ shows a correlation looking for a change (as observations on within error range 21,1% to 24,7%. location demonstrated) to socio-economic Among the PAS used very rarely may and cultural peculiarities. be mentioned the hallucinogenic drugs and Benzodiazepines (diasepam, lexotan, riv- the glue. Their use by IDU is 4,2%. Notably otril) turned out the most frequently used Bulgaria lacks almost completely the tradi- “medical PAS’’ - 23,1% of those surveyed. At tion in the use of this type of PAS, very the same time, with a relatively small group of revealing at that is the absence of supply. IDU - 5,2% -- we can speak about regular use. According to interviewees, only 0,4% state The specificity of the use of this medicine is that they can find LSD or mushrooms with that it has been pointed to as “second sub- their dealer. The analysis by age groups stance’’. The question, “Which substance and cities outlines more or less expected would be your first choice?’’, diasepam has correlations: almost 65% of the users are been indicated by scarcely 0,6%, while the aged below 25 and 44% are in Sofia. question “Which one comes second?’’, it has Glue is more popular than the hallucino- been the choice of 6,6%, i.e. runs ahead of genic drugs, 7,4% having used it during the methadone and cocaine as second choice. A last month. The surprise is that this type of possible explanation is that, unlike the above PAS is not used solely by adolescent Roma, described typical drugs, in this case IDU use as anticipated, but use is visible with all age the substance as a peculiar “medication’’. groups below age 35. The correlation According to interviewers, the drug users Roma-Bulgarians is 14,9% to 6,2%. explained that was a simple and accessible The use of legal PAS - alcohol and cig- means to counter some of the consequences arettes among IDU.

32 See Rusev, Atanas; Injecting Drug Users in Sofia. Sofia 2004, Initiative for Health Foundation

31 Table 18. Comparison of the four cities by alcohol use (%)

Bourgas Pleven Plovdiv Sofia Average Having used at least once during the last month 57,1 82,0 16,9 27,4 56,0 Users (every other day and more often) 29,6 26,0 3,1 18,4 20,3 N=501

Interpreting the data in regard to the use at present is rather poli-use of PAS than a of cigarettes, it is noteworthy that, even with typically heroin addiction as has been the the record high use typical for Bulgaria, the case 3-4 years ago. At the same time 95,1% registered among IDU, is consider- heroin use remains the primary PAS, yet is ably above the average for the country. used along with at least one other type of Alcohol, too, marks levels of use higher drug. The analysis shows, that for the four than the country's average. The question: cities the average use of PAS, excluding “How many times in the last month have alcohol and cigarettes, is 2,23 (median you consumed more than 200 gr concen- 2,00). As per results only16% of IDU use trate, or 2,5 l of beer?’’ - 44,1% have exclusively heroin, 24% use one more, answered positively33. 17,4% drink regularly while 22% two more PAS (see Chart 13). at that (every other day). The hypothesis As experts see it, poli-use as dominant that intensive alcohol use is a scheme for pattern has observably developed in the reducing heroin use did not get confirmed. recent years. A confirmation of this The correlation proved insignificant on the assumption is Sofia, where in the summer whole for the sample overall (p = - 0,186), of 2003 only 8,5% of the interviewees used just as for those who use it regularly (p = - nothing else but heroin, versus 50% in 0,096). The comparison by ethnicity princi- 199834. Juxtaposition of poli-use by cities ple on the survey demonstrated that the IDU shows, that in Sofia the poli-use is most of Roma origin use alcohol visibly less fre- widely spread, while the pattern heroin as quently in comparison to Bulgarians. At least once during Chart 13. Poli-use of PAS the month did use large quantities of alcohol 51,3% of the Bulgarian IDU, versus 14,7% of the Roma; regularly do so (every other day, or more often) 23% of the Bulgarians versus 6,7% with the Roma. Comparing cities, serious differences again stand out - see table 18.

2.2. The use of heroin and its alternatives

Data give proof to a statement that what is observable with IDU N=501

33 This study did not set it as its goal to analyse alcohol use among IDU overall, but only the intensive patterns of use. 34 See ,,Injection drug use: situation, trends and risks’’, ,,Initiative for health’’ Foundation, Sofia 1998.

32 single drug is strongest in Plovdiv - 39% average 2 to 6 months are needed from (see Table 19). the first injection to the regular use of heroin35. Comparing the first use with the Table 19. Comparison of the poli-use of PAS in the four regular use of opiates and heroin regis- cities(%) tered another interesting fact - before try- Bourgas Pleven Plovdiv Sofia ing injection use and before regular use of Exclusively heroin some 66% of the interviewees had heroin 14,1 12,0 39,0 8,5 used others opiates. Unfortunately, the 1 more PAS 18,2 35,0 29,0 18,4 survey cannot provide the answer whether 2 more PAS 31,3 21,0 17,0 21,4 3 more PAS 24,2 14,0 7,0 19,9 they were experimenting with “light 36 4 more PAS 2,0 8,0 6,0 12,9 drugs’’ . 5 more PAS 5,1 5,0 2,0 10,9 Contrasting the first use by ethnicity 6 more PAS 2,0 2,0 3,0 principle shows, that the representatives 7 more PAS 1,0 3,5 of the Bulgarian ethnic group start inject- 8 more PAS 2,0 2,0 0,5 9 more PAS 1,0 1,0 ing themselves at the average age of Average number 18,34 (median 18,00), while the Roma - at of PAS 2,2 2,1 1,2 2,8 19,94 (median 18,00). Higher average age N=501 of the Roma can be clarified by the fact that there are a significant number of per- 2.3. Starting and length of sons in this ethnic group who have start- injection use ed to inject themselves late - at an age above 30. The average starting age of injection Analysis by NEP attendants and non- use for the country is 18,64 (median attendants shows that the average age of 18,00). Juxtaposition by cities shows, that attendants is higher than that of non-atten- the city with earliest start of use is Plovdiv dants with all varieties of use - first injec- - 18,00 (median - 17,00), and the latest - tion use, regular use of heroin and regular Sofia - 19,08 (median 18,00), in Bourgas use of other opiates (see Table 20). the average age is 18,21 (median - 18,0), Juxtaposition by age shows an antici- and in Pleven - 18,77 (median 18,50). pated regularity: the lower the interviewee Extremely interesting is the answer to age, the earlier they have started with the question at what age the regular injection use (see Table 20 and Chart 14). drug use (3 or more days a week) starts. At the same time the hypothesis that the The survey manifested that with heroin or lower the age, the faster the transition other opiates (not methadone) it starts at between trial and regular use, proved right the average age of 18,03, median 17,00 . (see Table 21). With both groups “under The present study data give an answer 20’’ and ,,20 to 25’’ there is nearly a match to the question how long is the period of of the average age for transition - 1.7 to 1.8 transition from trial to regular use of hero- months; similar is the match with the age in. The analysis demonstrated that on groups of those aged 25-30 and 30-35

35 The ground for such an interpretation gives the T-Test of the two variables (mean 0,40; Confidence Interval of the Difference 95% - Lower - 0,59 Upper - 0,20). 36 It is unclear how to interpret the declared earlier ,,regular use’’ of other opiates as against the first injection use - the average age of ,,first injection use’’ is 18,64, the median being 18,00, while the age of ,,regular use of opiates’’ is 18,03, median 17,00.

33 Table 20. Correlations by average age over first and regular use

First injection Regular use of Regular use of use heroin others opiates Non- Mean 18,3 18,7 17,4 attendants Median 18,0 18,0 17,0 Attendants Mean 18,9 19,3 18,5 Median 18,0 18,0 18,0 N=501

Table 21. Distribution by age groups for span between first use and regular use of heroin

Average start age Median Average transition time from trial to regular use Under 20 16,08 16,00 1,8 months 20-25 17,63 17,00 1,7 months 25-30 19,37 19,00 5,5 months 30-35 23,28 23,00 6,0 months Over 35 27,92 26,50 5,6 years N=501

Chart 14. Distribution by age groups for span over time (see Chart 15). The survey between first use and regular use of heroin results confirm and uphold the hypothesis of the end of heroin epidemic in 2001. Yet only a longer observation of the new NEP attendants can confirm or reject the fact of drastic drop in the “hooking’’ of new IDU seen on the chart (see Chart 15). It is very likely that the harm reduction programmes need a period of 2-3 years to find new IDU, i.e. the established abrupt drop (see chart for years 2002 and 200337) may merely be reflecting this lag (much smaller number of IDU for 2003 may also be explicable in terms of the fact that the survey took place in the middle of 2003). On the other hand, the possibility to compare data on the start of injection use N=501 in the four surveyed cities for the first time where the transition takes some 5.5 to 6.0 made it possible to delineate the time months. lines of the “heroin epidemic’’. From the Analysis by years of “first use’’ and survey it becomes clear that in Sofia the “regular use’’ among respondents gives peak of the “heroin wave’’ is in 1998, while the exclusive opportunity to reconstruct in the other cities the peaks are as fol- how the “heroin epidemic’’ developed lows: Bourgas in 2000, Plovdiv and Pleven

37 Dipping IDU figures for 2003 may also be explicable by the fact that the survey took place in the middle of 2003.

34 Chart 15. Comparison of estimated development of heroin use with the year of starting regular heroin use by interviewee IDU.

* Left-hand scale shows the estimated number of heroin users in the country (as based on the number of those ,,seeking assistance’’ and the police registries, see ,,The Drug Market in Bulgaria’’, Center for the Study of Democracy, Sofia 2003. Right-hand scale shows the number of respondents in the sample according to the year when they first injected themselves a drug.

N=501

Chart 16. Four cities compared by start year of new IDU.

N=501 in 2001 (see Chart 16). Analysis by cities have been reached by the programmes. shows, that declining numbers of newly Hence, more evidence is there for the “hooked’’ in Sofia and Bourgas is a natu- “end of the epidemic’’, than for new IDU ral trend, since for 3-5 years they should technically not having been reached.

35 3. Types of risks with PAS use

3.1. Overdose

Overdosing has been pointed to as the first group: Pleven - 2 % and Bourgas - main reason causing death among IDU in 8,1%, and the second group Sofia - 21,9% Bulgaria. As per expert estimations between and Plovdiv - 31,0%. What are the reasons 1/3 and 1/2 of the death cases in the coun- why such huge, times differences are try38 can be accounted for in this way. observable, the survey findings do not Regrettably the overdosing problems have seem to provide the answer. A factor not been studied in Bulgaria, and the statis- undoubtedly contributing to the higher per- tics are much too controversial. According centage in Sofia and Plovdiv, is the Roma to the NCA the annual overdose death toll is ethnic group. The analysis of data in the last between 60 and 10039, while according to the six months gives 28,9% of the Roma having Ministry of Interior this figure is bigger - overdosed as against 13,1% Bulgarians. between 100 and 15040. Still the ethnicity factor cannot be described Data from the present survey show that as sufficient to explain such big differences. overdosing is a real threat for the Bulgarian Field observations on location did not pro- IDU. As seen in the table (see Table 22) vide answer to these differences. 16,6% have overdosed at least once in the The attempts to find correlations demon- last six months. 7% of the IDU have over- strated no connection between frequency of dosed more than once during the same injection use and overdosing, just as interval. This group should be considered between alcohol abuse and overdosing (the particularly risky in regard to death. hypothesis was that alcohol use might be leading to less careful heroin use). Other Table 22. Overdose numbers hypotheses were refuted of overdosing tak- Number of times Number of cases % ing place after coming out of prison and 1 48 9,6 with persons' participation in methadone 2 16 3,2 programmes. On the other hand there is 3 6 1,2 certain correlation between age (experi- 4 6 1,2 5 1 0,2 ence) and overdosing (see Chart 17). With 8 4 0,8 the fluctuating exception of the age group of 9 1 0,2 30-35, the data show overt tendency of 10 1 0,2 decreasing overdosing with growing age. N=83 The cross-section by education manifest- Juxtaposing by cities discloses various ed, yet, as expected, that more frequently degrees of vulnerability regarding overdos- overdosing are mainly the IDU with lower ing. The distinction is very clear between the education: 29,2% with no education and

38 It is disputable whether the impurities added to injected PAS in the country are not the more significant death factor in Bulgaria. 39 See newspaper Every Day 11February 2004. 40 The National Institute of Statistics cannot supply correct mortality statistics related to drugs. The main reason is that the relatives of the deceased prefer not to enter the actual cause of death in the death certificate. According to the press centre with the Ministry of Interior in 1999 in Bulgaria 57 died of drug overdose (aged 14 to 18 - 11, 19 to 30 - 44, above 30 - 2). In 2000 102 died in Bulgaria of overdose. For 2001 75 have died of either overdose or low quality stuff, as per a study of the Center for Social Research. And in the first six months of 2002 there were 17 death cases. For 2003 no government institution has announced data on overdose deaths.

36 Chart 17. Percentage of those overdosing by age (%) use more than one place and they change their behaviour depending on the season. During the warm seasons the use of public places grows abrupt- ly, while during the cold periods that is replaced by use at home, or at friends' homes, or other accessible premises - staircases of residential buildings, entrances, attics and cellars. Observations after the amendments to the drugs legislation from the spring of 2004 show that the public places get more and more overtly avoided. In view of this when developing strate- N=501 gies for the collection of used needles, basic education, versus 12% with second- syringes and consumables NEP must be ary education and 6,7% with university highly adaptive not only to season, but also degree. to social changes - like activity of the police, The field observations revealed the most the public administration, the media, etc. common cause for overdosing is the difference in the purity of the street heroin. In 3.3. Mobility of IDU Sofia IDU share that “rarely do they come across very pure heroin, and overdosing A very important issue when assessing takes place when they get hold of a weaker risk is the level of mobility among IDU. dose, and in a haste to ,,feel’’ the effect, Unfortunately, as of now no empirical data take a second dose almost immediately’’. was available on how far encapsulated are The observations in Plovdiv go along the the drug users, how far they buy and use same lines - very low quality heroin, that outside of the places where they reside. The probably gets overdosed with the same present survey showed that we can speak intentions. about considerable mobility in the country, variation by cities ranging from 50,7% in 3.2. Places of use Sofia to 100,0 in Plovdiv (Table 23). The most common reason respondents Two patterns exist almost dividing the quoted as reason for their mobility is “to buy Bulgarian IDU with regard to where they drugs’’. As compared to this, injection use inject themselves. The first one is “around’’ elsewhere is much rarer, while the use of home and 46,5% use it as first choice, the somebody else's instruments is times below second one is preference for outside of buying. The other important contrast is by home. Choosing where to inject outside of average sharing of injecting instruments for home, 29,5% go for public places as first the respective city - the study shows that in (gardens, entrances to residential buildings, their own cities IDU have considerably more etc.), 11,2% speak about a friend's home, risky behaviour (see last row of Table 21). followed by less significant places - aban- Analyzing the settlements where IDU doned houses - 6,0%, and the dealer's bought drugs it is seen that the surveyed home - 2,0%. Data demonstrate that IDU cities have different patterns of supply.

37 Strikingly enough in Table 23. Mobility in the four cities (in the last six months) % Sofia one settlement pattern is prevailing Bourgas Pleven Plovdiv Sofia Bought drugs in other cities 73,7 59,0 100,0 50,7 as source of supply Injected in other cities 68,7 41,0 38,0 45,3 (32,8 have bought Having used already used needles from one place only, and syringes in settlements outside and 8,5% -- from two of the city where they live 7,1 8,0 5,0 13,4 Average use of used needles settlements). In and syringes (in general) 51,5 30,0 68,0 63,2 Plovdiv the predomi- N=501 nant pattern is 2 settlements, while in Bourgas and Pleven Table 24. IDU distributions according to the number of settle- three places are relatively well repre- ments, where drug was obtained from, in the last six months sented (see Table 24). (the figure shows number subtracted by the settlement where The analysis of where stuff was the IDU lives) bought from, demonstrated Pernik as Bourgas Plovdiv Sofia Pleven source ¹1 for Sofia with 35,8%. (see 1 settlement 31,3 67,0 32,8 26,0 Map and Table 25). These results get 2 settlements 22,2 25,0 8,5 16,0 conformed by field observations which 3 settlements 15,2 6,0 5,0 14,0 disclose that in the summer of 2003 a 4 settlements 4,0 1,0 1,0 2,0 5 settlements 1,0 1,0 3,0 1,0 great number of users travelled to 6 settlements 0,5 41 Pernik to acquire better quality heroin . N=501 Map. Where IDU from 4 cities bought drugs

41 Pernik is a town of population 85 thousand situated 25 kilometres from Sofia. As per police data the heroin use there corre- sponds to that in country's large cities (see Table 34) with its 100-150 users. The main reason for Pernik turning into a ,,preferred place for buying heroin’’ is that the dominant criminal group there does not play by the rules of the big drug groupings in Sofia and sells better quality heroin at lower prices.

38 Table 25. Comparison of IDU from the 4 cities by where they demonstrated 9,0% of the IDU had bought drugs(%) bought drugs from small settlements around them. Bourgas Plovdiv Sofia Pleven Sofia 31,3 23,0 99,5 35,0 From the point of view of the risk Bourgas 99,0 14,0 1,0 3,0 involved, the survey data make it pos- Plovdiv 6,3 99,0 9,5 10,0 sible for NEP, interested NGO and Varna 53,6 13,0 9,0 20,0 government institutions to trace major Pleven 0,0 5,0 10,9 94,0 IDU flows between the respective set- Pernik 3,0 2,0 35,8 Sozopol 6,1 5,5 2,0 tlements. Thus over eventual critical Sliven 8,1 1,0 situation being localized in some of Rousse 5,1 7,0 the settlements related to blood-trans- Stara Zagora 6,3 2,0 1,0 1,0 mitted or sexually-transmitted dis- Blagoevgrad 1,0 5,0 1,0 eases with IDU, active preventive Nessebar 7,0 1,0 Yambol 5,0 0,5 intervention can be planned. For Cherven Briag 0,5 19,0 instance a problem situation in Pleven Lovech 5,0 should focus attention not just to Pazardjik 1,0 4,0 1,0 1,0 Sofia, but also to cities such as Varna Blagoevgrad 3,5 1,0 and Cherven Briag. N=501

Similar is the situation in Bourgas, where 3.4. Frequency of injection use travelling to Varna for the purpose of obtaining quality heroin has history of long The act of injecting is among the most years. Varna is an important supply source serious risks for the drug users and the sur- for Pleven, too as per location observa- vey provides good opportunities for deter- tions. The survey provided evidence that mining its features and specifics in the coun- 20% of the IDU have bought from Varna. try. A point of departure for the study can be Somewhat paradoxical is that Sofia is the the frequency of injecting and use of PAS. source ¹1 for Pleven (with 35,0%) and Contrasting the 4 variables42 registering the Plovdiv (23,0%) given that over 1/3 of the frequency of injection behaviour, we get that capital city IDUs travel to Pernik for better the average daily number of injections in heroin. Apart from travelling to the respec- the country ranges between 1,42 times and tive settlement for the purpose of supplying 1,48 times (see Table 26). cheaper stuff, the findings can be Lesser number of injections on average, explained in terms of temporary migration registered in answer to the question on the of the population for studies or work. For “number of injections in the last six months’’ instance, according to field observations, is probably explicable in terms of having IDU NEP “attendants’’ in Sofia are from periods of lower use and interruptions, IDU Pleven and vice versa. The summer period declare they have for various reasons. when the survey was held additionally Another possible explanation is lowered IDU enhances the number of settlements for estimations. Juxtaposing declared injection vacation reasons. Data on all four cities behaviour and heroin consumption shows

42 The 4 variables registering the frequency of injection behaviour show certain contradictions, which can be justified by IDU problems remembering things and making judgments. Yet data can be described as sufficiently homogeneous to be considered a good empirical basis.

39 Table 26. Average number of injections

Number of Number of Number of Number of Average injections injections in injections in injections in number of yesterday the last the last the last six heroin use week month months days per month Average (Mean) 1,46 9,95 44,42 204,27 20,3 Median 1,46 7,00 28,00 120,00 25,0 Recalculated injections on average per day (Mean) 1,42 1,48 1,13 Recalculated injections on average per day (Median) 1,00 0,93 0,67 N=501

Table 27. Comparison of injection practices by settlements

Number of Number of Number of Number of Average injections injections in injections in injections in number of yesterday the last the last the last six heroin use week month months days per month Bourgas Average (Mean) 1,2 8,2 34,8 169,2 20,6 Median 1,0 5,0 23,0 100,0 25,0 Pleven Average (Mean) 0,5 3,5 15,1 84,5 14,2 Median 0,0 2,0 12,5 70,0 15,0 Plovdiv Average (Mean) 2,5 16,7 96,1 297,6 28,0 Median 2,5 14,0 41,0 240,0 30,0 Sofia Average (Mean) 1,6 10,9 43,3 259,4 19,3 Median 1,0 7,0 30,0 180,0 29,0 N=501 that the average number of injections a day Pleven. Data reinforce cities' specificities is significantly higher than the declared injec- established over the analysis of heroin use. tion use of heroin. This fact may have two For the sake of better evaluating the injec- mutually complementary explanations. The tion behaviour an attempt was made to ana- first one is that, as demonstrated by the sur- lyze the 5 variables registering the frequency vey, a large portion of “surrogate’’ PAS such of injecting and heroin use by means of clus- as amphetamines, methadone and even ter non-hierarchical analysis, obtaining cocaine, get injected. The second explana- meaningful results mainly with K-means clus- tion goes along the lines that IDU often make ter, still only implementing two clusters (see several injection attempts until they success- Table 28). The first centurion is found among fully inject the respective PAS. those using a little more often than every Comparison by cities manifests that inten- other day and those injecting themselves sity of injecting varies a lot (see Table 27) fol- once à day - ,,cluster moderate IDU’’; the lowing on the whole the consumption of hero- second one is among those who use heroin in (the last column of Table 27). Unmatched almost every day and inject themselves an leader in the intensity of injection behaviour is average of three times -- “cluster intensive Plovdiv, and last, with times lower figures is IDU’’. These findings give grounds to inter-

40 Table 28. IDU clusters

Cluster 1 (,,moderate’’) Cluster 2 (,,intensive’’) Average number of days of heroin use 18 29 Number of injections yesterday 1 3 Number of injections in the last week 6 24 Number of injections in the last month 24 103 Number of injections in the last six months 128 606 N=501

Table 29. Types of IDU

Group's Number of Number of Number of Number of percentage injections injections in injections in injections in presence in yesterday the last the last the last six the sample week month months ,,Moderate IDU’’ 12,7 0,1 1,1 16,6 85,2 ,,Regular IDU’’ 31,3 0,6 9,3 23,7 124,2 ,,Intensive IDU’’ 13,5 0,8 19,4 59,0 229,7 ,,Every day IDU’’ 16,0 2,0 23,2 88,4 354,0 ,,Highly dependent IDU’’ 21,2 3,7 38,3 217,8 589,7 ,,Incohesive IDU’’ 5,3 0,8 4,2 15,2 183,5 ,,Average’’ 1,5 17,7 78,6 272,0 N=501

Table 30. Comparison of the types of IDU by cities (%)

Bourgas Pleven Plovdiv Sofia ,,Moderate IDU’’ 11,2 22,2 14,9 ,,Regular IDU’’ 38,8 54,5 14,6 23,9 ,,Intensive IDU’’ 15,3 14,1 14,6 11,9 ,,Every day IDU’’ 20,4 3,0 20,8 17,9 ,,Highly dependent IDU’’ 11,2 1,0 50,0 22,4 N=501 pretations that the IDU in the country mainly they inject themselves between once and belong to these two types. twice 12 to 29 days a month. The fourth Lack of enough efficiency of the cluster group was ,,every day IDU’’ who claim that analysis prompted looking for ways of they inject themselves more often than 21 grouping IDU as based on the findings of the days and do it twice a day. The fifth group reports on the 4 cities and the field observa- was called ,,highly dependent IDU’’ and tions. As a result six groups were formed these are persons who inject themselves (see Table 29), which were allotted provision- three or more times every day. The sixth al names as based on the frequency of group was called ,,incohesive IDU’’ compris- injecting. The first group was called ,,weak ing 5,3% of the sample, who by frequency of IDU’’ stating that up to 5 days a month they injection behaviour stand between ,,the mod- have injected themselves once a day. The erate IDU’’ and ,,the intensive IDU’’, yet due second group was called ,,regular IDU’’ and to very incohesive behaviour patterns report- they have injected themselves from 6 to 20 ed were not subject to further analysis. days a month in 90% of the cases once. The Implementing this grouping in the analysis third group was called ,,intensive IDU’’ and by cities a much more detailed and compre-

41 Chart 18. Comparison of IDU types by ethnicity (%)

N=501

Chart 19. Contrasting ,,attendants’’ and ,,non-attendants’’ as IDU types (%)

N=501

Chart 20. Comparison of the IDU types by age (%)

N=501

42 hensive picture is attained confirming and practices. To assess what portion of the enriching the average use data illuminated IDU have risky behaviour and what is its above. intensity, two questions were asked. The With regard to ethnicity background, the first one was about how many times since Roma ethnic group is represented by very year 1980 needles and syringes have been intensive injection behaviour, while various shared, and the second - about how many patterns of intensity with the Bulgarian IDU times in the last six months they have been come nearly evenly distributed among the shared43. Survey data demonstrated that group (see Chart 18). 55,1% of the IDU have at some time at Comparing “attendants’’-,,non-atten- least once shared a needle or a syringe dants’’ again the regularity is validated that and 27,4% have done that in the last six “the attendants’’ have more risky behaviour months. Such high scores were expected, (see Chart 19). Analysis by age does not and even seem low in view of the technolo- show any clear correlation (see Chart 20). gy of heroin use, the environment where it is used (friendly and group relationships, cul- 3.5. Using shared injecting ture of sharing), the way it is started, the instruments degree of marginalization and encapsulation of typical IDU, etc. In this context this Thus described injection use itself is an survey's goal is rather to evaluate the levels indirect risk. Direct risk can be called the of risk and what the proportions are using of shared needles and syringes, the between different types of IDU. As seen on sharing of attributes (caps, filters, water, the chart (see Chart 21) the question on etc.), the sharing of PAS in the same ever shared needles and syringes provi- syringe (mainly heroin) and other similar sionally outlines 3 risky groups. The first, “highly risky’’ group accord- Chart 21. ,,Ever since 1980 have you injected yourself with a ing to data covers 11,2% of needle or a syringe that had been used by somebody else?’’ the IDU - persons having shared syringes more than 50 times. The second, “medium risky’’ consists of 23% of the IDU (shared between 5 and 50 times) and the third, “low risky’’ one - 20,4% (below 5 times). The hypothesis that the more frequently needles and syringes are shared, the more risky are the persons, is very clearly validated drawing a comparison with hepatitis infections lev- N=501 els (see Chart 22).

43 The first question is ,,Ever since 1980 have you injected yourself with a needle or a syringe that had been used by somebody else?’’ the second one is, ,,In the last six months, how many times have you injected yourself with a needle or a syringe that had been used by somebody else?’’?’’

43 Chart 22. Comparison of shared instruments figures with the The actual degree of risk number of hepatitis infections involved with IDU can be further weighted by the block of questions specifying when in the last six months instruments were shared. (see Chart 23). Matching the question of how many times instruments were shared against the questions registering the use in the last six months demonstrate certain contradictions. For N=501 instance, those having said that they have never shared needles Chart 23. ,,How many times have you injected yourself with a and syringes, later say that they needle or a syringe that had been used by somebody else?’’ (%) have done so yesterday or in the course of the previous week, etc. Certain inconsisten- cy arises between the four questions where the interviewees state that they have shared in the last week needles and syringes, later stating that they have not done so in the last six months. To attain a single rating comprising all having declared that they have shared instruments, the count proce- N=501 dure for the 5 questions was

Chart 24. Provisional distribution of risky IDU

44 Table 31. Comparison of the use of shared instruments by the types of IDU (%)

Not having Up to 5 From 6 to More than Does not shared times 50 times 50 times know ,,Moderate IDU’’ 16,1 6,1 13,3 10,7 ,,Regular IDU’’ 37,5 36,4 22,1 16,1 33,3 ,,Intensive IDU’’ 11,2 19,2 11,5 16,1 33,3 ,,Every day IDU’’ 15,2 15,2 16,8 17,9 33,3 ,,Highly dependent IDU’’ 14,3 16,2 32,7 35,7 * Difference to 100% is due to incohesive IDU being excluded from calculations implemented. The result has been represent- strongest with the group of “highly dependent ed graphically including everybody who has IDU’’ (see grey cells in Table 31). answered any of the questions positively. The distribution by cities of “non-users’’ of Those exposed to lowest risk having shared syringes shows that serious differ- answered positively to one question only take ences exist between the cities. Sofia and the periphery; and those having answered Plovdiv come again with the most risky IDU positively to all five questions, facing highest and the main reason may again be looked for risk - in the centre (see Chart 24). in the ethnicity distribution. As seen from Juxtaposing the risky use with the above Chart 26 the Roma IDU are in the more risky implemented 5 types of IDU, it becomes groups and this contributes for the smaller clear, that just with some IDU there is visible number of persons not sharing instruments in correlation between the intensity of injecting Sofia and Plovdiv. and the using of shared needles and Comparing “attendants’’ - “non-atten- syringes (see Table 30). This correlation is dants’’, as with other types of risky behaviour,

Chart 25 and Chart 26

Chart 27 and Chart 28

45 Chart 29. Distribution by age of the answers have never shared instruments (%)

the “attendants’’ are again more risky risky behaviour is most frequently observ- (Chart 27). Interestingly enough, the able over the injection use of drugs44. In this female IDU turn out less precautious than respect, too, Bulgaria is getting closer to the the male ones (see Chart 28). world practice. If before 1999 available sur- Evaluating the age one can only rely on veys45 give practically no evidence of injec- the answer “have never shared’’ (Chart 29) tion use in prisons, the present survey data due to the fact that with growing age IDU register a visible change. According to sur- gain proportionally more experience as vey data 15,2% of the IDU have been in drug users, hence the longer they have prison, 3,9% have been behind bars more been using drugs, the more times they than once. While being in prison 36,8% of have shared needles and syringes. the respondents say they have used drugs. In regard to lending used personal Recalculated as against all survey respon- instruments in the last six months things dents, 5,6% have experience using PAS stand somewhat differently. Borrowing inside prisons, and 2,4% i.e. nearly half, used instruments occurs more frequently have injected themselves with shared nee- not just among the commercial sex work- dles and syringes. These findings have ers, but also with the Roma, however that manifested that as compared with all IDU holds no relation to age. population, the country's prisons do not yet look like a serious risk generator, still in view 3.6. Time in prison of the speed of drug spread growing at pen- itentiary institutions, it can be prognosticat- As demonstrated by worldwide experi- ed that within 2-3 years NEP will have to pay ence, prisons are among the places where special attention to this group.

44 Drug Use and Prisons: An International Perspective, 2000, Glasgow Caledonian Univ., Scotland, David Shewan, John B. Davies, John Booth 45 Drug users in Bulgarian prisons, Sofia 1999, Eleonora Nesheva and Philip Lazarov

46 3.7. Patterns of risky sexual age shows in regard to the number of part- behaviour with IDU ners in the last six months respondents below 30 have almost equal average num- The survey dedicated special attention to ber of partners and equal median. After 30, the risk related to IDU sexual contacts. In as registered by the survey, an abrupt drop this context key for the country should be takes place of the number of partners (see considered the possibility HIV-infected per- Table 32), which can be interpreted as sons among the drug users to sexually reduced riskiness. pass it on. Due to their encapsulation and Juxtaposition by cities displays a varied marginal position in society IDU are consid- picture as to average figures, yet that ered a community among which a HIV epi- seems to be mainly due to some extreme demic is likely under the conditions in cases, and with the significantly more reli- Bulgaria. able median differences are detectable The likelihood of such a scenario gets mainly between: on the one hand, the cities confirmed by the survey which discards a Bourgas and Pleven; and on the other - widely believed idea in Bulgaria that the Plovdiv and Sofia (see Table 33) heroin users have low sexual activity. Data Concerning the ethnicity distribution manifest that 91,6% of the respondents between Bulgarian IDU and Roma IDU have had sexual contacts in the last six anticipated differences are detected. The months46. What is more, the average num- question about permanent sexual partners ber of sexual partners the interviewees in the last six months with the Bulgarians declared they had had in the course of their the average number is 1,97 at median 1,00; sex life are 42,8 (mean) and median 25,0. while with the Roma ethnic group 5,34 is the Within the last six months 55,6% of the IDU average number at median 1,00. The ques- claim they have a permanent sexual part- tion about other (casual) partners with the ner, yet matching that with the question Bulgarians 5,99 is the average number at whether they have other (casual) sexual median 3,00. For the Roma the average partners, it turned out that around 41% also have more Table 32. Average number of sexual partners among IDU by age than one intimate friends. On this variable the average Äî 20 ã. 20-25 ã. 25-30 ã. 30-35 ã. Of 35 ã. Average 4,21 4,25 4,47 2,81 2,92 number of sexual partners in Median 2,00 2,00 2,00 0,00 0,00 the last six months have been N=501 6,4 persons, median 3,0 (that is 2/3 IDU of those claiming Table 33. Average number of sexual partners among IDU by cities that they have more intimate partners). Bourgas Pleven Plovdiv Sofia Evaluating the risk one Permanent partners average 1,25 1,38 6,99 1,28 must bear in mind the speci- Permanent partners median 1,00 1,00 1,00 1,00 Casual partners average 7,05 6,81 4,11 6,85 ficities in different IDU sub- Casual partners median 4,00 4,00 3,00 3,00 groups. The distribution by N=501

46 It is important to mark for the purposes of NEP the different patterns within the Roma communities. In Sofia some 25% of the Roma IDU do not have sex life (versus 4,3% of the Bulgarians) as being rejected by their own community. In Plovdiv - the second largest city by number of Roma IDU - such isolation is not observable in the Roma neighbourhoods, as per the survey data. The respondents having no sexual contacts are 6,6% among the Bulgarians and 6% among the Roma.

47 number is 8,34 at median 3,00. Juxtaposing sex workers as against 17% of the women NEP ,,attendants’’ and ,,non-attendants’’ (just 3 cases). more conservative is the behaviour of the The type of survey makes it hard to say ,,non-attendants’’. The average number of what the exact presence is of commercial regular partners among the ,,non-atten- sex workers among the IDU. As per the dants’’ is 1,89 (median 1,00), while with the present survey the question whether ,,sex ,,attendants’’ it is 2,90 (median 1,00). With has been carried out for money or drugs’’ in the casual partners the difference is less the last six months has been answered pos- conspicuous - the average number is 5,85 itively by 16,4%. As regular commercial sex (median 3,00) for ,,non-attendants’’ and 6,84 workers, yet can be defined some 10% of (median 3,00) for ,,attendants’’. the interviewees (at least once a week). The In terms of sexual orientation the survey persons having stated that they provided registers that 15,5% of the sample are bisex- sexual services against payment or drugs ual. Within this group 19,0% of the women display several specificities. Data show that have declared that they are bisexual versus 30,5% of the women IDU have been com- 14,6% with the men. Homosexual have mercial sex workers versus 4,8% with the defined themselves 1% of the men and 1% men. Men, however, provide sexual servic- of the women. Importantly, from the point of es less intensively - an average of 2,4 times view of risk bisexual behaviour among men weekly, while with the women the average constitutes considerably more serious risk number is 13,2 times. Analysis verifies that in comparison to that among women due to the female commercial sex workers consti- the fact that 38% of them are commercial tute two groups. The first group is occupied

Chart 30. Juxtaposition of sexual behaviour to using condoms

N=501

48 by persons to whom selling sex services is among the IDU is fully grounded. Having so the primary source of income and the num- many sexual partners, we see that with the ber of their sexual contacts is more than 3 first two groups less than half of the intervie- times a day. The second group is made wees use condoms regularly. With the com- women to whom this is side, or casual mercial sex workers as per analysis, actual- income (their first source of income are ly only those having small number of sexual reportedly parents) and they have 2-3 sexu- contacts do not use condoms. With a single al contacts for money a week on average. exception, everybody practising more fre- Of special relevance in regard to sexual- quently than once a week, uses condoms. ly-transmitted infections (STI) is the using of Evaluating how far IDU attempt to protect condoms. Along these lines the use of such their partners and clients, of interest is the protective means can be considered an analysis by sexually-transmitted infections indicator as to how far risky the sexual (STI). According to the survey 6,9% of the behaviour is with different IDU. In order to drug users have had some STI. Upon juxta- conduct a more efficient analysis IDU have position it was demonstrated a very small been divided into three groups depending percentage of the infected, who know that on the type of their sexual behaviour. The they are infected, protect their sexual part- first one is of the least risky behaviour and ners and clients. With the commercial sex includes persons with permanent partners, workers some 38% of those infected do not the second degree of risk concerns per- always use condoms. As to the IDU with sons with non-permanent partners, and the casual partners, 75% of those infected do third, the most risky are the commercial sex not use condoms. Notably, the group sec- workers. Grouping them in this way reveals ond in risk exposure (the one with tempo- that IDU make attempts, depending on their rary partners) has highest presence of STI- type of sexual behaviour to use means of infected - 12,1%. Among the least risky protection (see Chart 30). group, IDU with permanent sexual partners, The survey gives grounds to draw con- 56,0% of the STI-infected do not regularly clusions that the hypothesis of high risk use means of protection.

49 4. Evaluation of risks and the place of harm reduction programmes

Among the survey's primary goals was to of all drug dependents (see Table 34, grey review the impact of the harm reduction columns). programmes. To set the framework of this Evaluating the NEP impact, it should also analysis the “coverage’’ effected by the pro- be taken into account that the programmes grammes of the injection drug use in the operate in cities of different size and with country is to be described, i.e. what portion different numbers of IDU. Matching the rat- of the IDU are able to access NEP in their ings of the number of IDU in the cities and city. According to most expert estimations the number of NEP “attendants’’ presents as at present in Bulgaria the injection drug different degree of “coverage’’ (“penetra- users (mainly heroin ones) are totally tion’’) in the drug users' communities. between 7 and 30 thousand47. Various sur- Comparing “unique attendants’’ that is, per- vey data give evidence that more than 90% sons who have at least once used NEP of those drug users are concentrated in the services52 in the 4 cities and the estimated cities of over 50 thousand residents48 (these total number of IDU in these cities, with all cities number 21 in the country49). At the due provisions gives the following levels of same time the greatest number of drug “coverage’’: For Sofia - 50-70% over approx- dependents is concentrated in the country's imately 5000 “unique attendants’’ and 7000 - 4 largest cities - Sofia, Plovdiv, Varna and 10 000 heroin users, for Plovdiv - around 25- Bourgas, and still more smaller cities like 30% “coverage’’ over 670 “unique atten- Blagoevgrad, Rousse, Pazardjik, Pernik and dants’’ and 2500-3000 heroin users, for Pleven. NEP are present in 4 of those cities: Bourgas - 45-55% over 650 “unique atten- Sofia, Plovdiv, Bourgas and Pleven. If we dants’’ and 1200-1500 heroin users and for take that drug dealer detentions data of the Pleven - 70-85% “coverage’’ with 415 Ministry of Interior50 by districts51 roughly “unique attendants’’ over 500-600 heroin reflect the proportion of the number of drug users (together with Cherven Briag)53. At the users by cities, it can be asserted that with same time the survey experience undis- their presence in the four cities, NEP have a closed that the number of unique atten- national coverage of between 60% and 70% dants is to be evaluated very cautiously due

47 The lowest estimations of heroin use are Ministry of Interior's - between 7000 è 8000. As per analysis of the Center for the Study of Democracy, the number of heroin users can be assessed approximately between 15 000 and 25 000. According to the evaluations of the National Center for Addictions, there are around 30 000 heroin users in the country. 48 Several settlements have not too large groups of IDU which are exceptions to this rule: Radomir, Dupnitsa, Cherven Briag, Petrich and Sandanski. The presence of IDU registered in small resort settlements like Sozopol, Nessebar, Pomorie and others is explicable mainly in terms of presence of big cities residents during the vacation season. 49 As per latest census of population held by the National Institute of Statistics. 50 Unfortunately the sole relevant information for comparison on a national level is the operative police statistics. The problem with this type of information is that it is highly contingent on the specificity of the district police departments (DPD). Data may get locally distorted with more active DPD, and over detentions of the same drug user within the same year. Still, juxtaposing police data to other independent sources proves that they present a relatively sound basis for comparison. 51 Although, the statistics are for a district, over 95% of the detentions take place in the respective district centre, and that gives grounds to talk about the city's IDU. 52 Utilizing the services of NEP, attendants receive unique code number which, apart from guaranteeing their anonymity, evades the possibility of counting one and the same person more than once. 53 The suggested figures of total number of IDU for the respective city are debatable, the number of NEP attendants changes in a dynamic way. This is why the estimations are more or less provisional.

50 Table 34. Percentage shares by detention districts Apart from the indicator “unique attendant’’ showing the maximum number of Districts 2002 (%) Prior to 30 persons reached by the programmes since September 2003 (%) they started operation, another relevant City Sofia 50,49 51,56 Varna 9,34 11,65 characteristic of NEP is the number of their Plovdiv 10,01 9,62 “regular attendants’’, that is IDU who fre- Bourgas 4,49 3,59 quently use the services provided by the Blagoevgrad 3,70 3,46 programmes. According to programme Rousse 1,09 2,24 Pazardjik 1,21 2,03 data the “regular attendants’’ count Pernik 1,27 1,56 between 1/5 and 1/3 of the number of Pleven 2,25 1,49 “unique attendants’’. Attempting to Kyustendil 1,33 1,29 schematically represent the work of the Stara Zagora 1,46 1,29 programmes, this can be depicted by Haskovo 1,09 1,29 Montana 1,15 1,08 means of three concentric circles. The first Sliven 1,52 1,08 one is the widest and includes all IDU in the Dobrich 2,00 0,95 respective city, the second one gives the Smolian 0,85 0,88 ,,unique NEP attendants’’ and the third is a Gabrovo 0,91 0,81 “core’’ representing the ,,regular NEP Lovech 0,36 0,68 Veliko Tarnovo 0,3 0,54 attendants’’ (see Chart 31). NEP practice Shoumen 0,3 0,47 has shown that the group of ,,regular atten- Vratsa 0,36 0,41 dants’’ is very dynamic while some atten- Silistra 0,18 0,41 dants remain steady for years, others dis- Razgrad 0,49 0,34 Kardjali 0,55 0,20 appear after a certain period of regular vis- Yambol 1,03 0,20 its, then come back again, still others come Vidin 0,42 0,14 several times and then stop, etc. Region Sofia 0,36 0,14 Analysis of NEP raises the question of Targovishte 0,36 0,14 what are the prognoses about the IDU community. Stepping on available data, it to the large number of persons using more can be said that despite the smaller num- than one code. Juxtaposing NEP registries ber of new heroin users after the end of the with the actual number of IDU gives heroin epidemic in 2001 (see Part 2), and grounds for a reduction of the unique atten- regardless of the receding intensity of hero- dants' numbers by 30-40%. Thus the cover- in use, expert estimations hold that the age for Sofia, for instance, can be estimat- number of those exiting the IDU community ed at 30-40%, in Bourgas - at 30-35%, etc. It is not sufficient to claim that there is a rever- must also be taken into consideration that sal change of tendency from expansion to the size of a city creates different conditions shrinking of this community54. This is the for work: the capital city with its 1,1 million reason why it is very likely that in the sever- residents and more than 50% of all IDU is al upcoming years, the total (cumulative) much more difficult to “cover’’ versus a 120 number of IDU will continue to increase, thousand city, for instance, like Pleven. although the heroin market will continue to

54 It is extremely complicated to estimate what the actual number is of those ,,exiting’’ IDU. Apart from the arguable death toll figures (see for more detail the overdosing section), it is not clear what portion of the IDU per year temporarily or permanently leave the country, there is no authentic information about the cured and temporarily break offs (the situation with methadone programmes is much too debatable and it is not clear what portion of their participants have actually fully stopped their heroin use).

51 Chart 31. Scheme of the three groups of IDU - non-attendants, unique attendants and regular attendants

reduce in consumption size55. must not be turned into an indicator of effi- Having schematically outlined the frame- ciency, since the exchange of needles and work of NEP operation the question arises syringes is affected by various factors like of the pointers as to how their activity can different intensity of use, economic situa- be described in terms of covered IDU. This tion, attitude of sales people at pharmacies, in mind a worthwhile possibility is juxtaposi- etc. tion of the alternative sources of new nee- A different cross section to the question dles and syringes in the last six months. how far does the operation of NEPs reduce As seen from the data (see Table 35), NEP the risky behaviour among IDU is the com- are the second in importance source, which parison of the characteristics of the “atten- can be interpreted as their being undoubt- dants’’ and “non-attendants’’. The prelimi- edly an extremely important factor as nary hypothesis was that the programmes source of needles and syringes. Here it “non-attendants’’ should be more risky than does not matter what percentage of the IDU “the attendants’’. This presumption was are using NEP as first source, and what - as fully rejected by the survey data. As has “reserve’’ - the fact is that NEP secure a vis- been demonstrated in previous parts, in ible reduction of the risk. Bulgarian context “the NEP attendants’’ are Regrettably, due to absence of other more risky along almost all types of risky comparable data on the NEP activity, the behaviour - in regard to the number of injec- sole juxtaposition that can be made is by tions, the using of shared needles and the average number of needles and syringes, the using of protective means dur- syringes by cities (Table 36). This, however, ing sex, etc. The reasons for that appear

55 There are more pessimistic scenarios referring to the Western experience, where after declines of several years drug consumption is observably restored. Along these lines it can be assumed that after the crisis in heroin supply in 2002-2003, a new wave of cheap heroin can be expected, as the country is located on the main heroin road from Afghanistan through Turkey to Western Europe. Another important prerequisite is that the population's income levels will continue to rise and better quality heroin will become affordable for more.

52 Table 35. Comparison by source of new needles and syringes for the last six months

Bought from Bought from NEP % Given by Obtained in pharmacy % elsewhere: % friends or another way others: % % s Average (Mean) 68,5 16,7 55,2 33,0 39,8 Median 82,5 10,0 50,0 20,0 10,0 Mode 100 10 100 10 10 N=501

Table 36. Sources of needles and syringes by cities

Bourgas Pleven Plovdiv Sofia bought from from NEP bought from from NEP bought from from NEP bought from from NEP pharmacy % % pharmacy % % pharmacy % % pharmacy % % Number of cases (n) 95 52 88 48 86 71 168 127 Average 71,4 43,6 72,4 59,7 60,3 50,2 68,8 61,1 Median 90,0 45,0 90,0 65,0 60,0 50,0 90,0 70,0 Number Average Number Average Number Average Number Average of injections number of injections number of injections number of injections number in the last of heroin in the last of heroin in the last of heroin in the last of heroin six months use days six months use days six months use days six months use days per month per month per month per month Average (Mean) 169,2 20,6 84,5 14,2 297,6 28,0 259,4 19,3 Median 100,0 25,0 70,0 15,0 240,0 30,0 180,0 29,0 N=501

more evident over comparison of the socio- deviant behaviour, have been tested more economic and demographic characteristics (Chart 32). Moreover, 30% of the intervie- of the IDU (see Part 1). It turns out that wees have done the testing in 2003, i.e. less Bulgarian NEPs are a venue for IDU of low- than six months before the survey took est social status - persons with lower edu- place, while 25% have been tested in 2001 cation (see Table 3), persons without legal and 2002. employment, representatives of the Roma In different cities the number of those minority (including those isolated from their tested is different, in percentage terms three own community), persons with no social of them - Bourgas, Plovdiv and Pleven have and health insurance, selling sex, etc. In approximately equal shares of tested - near- this context it can be presumed that the ly half of the interviewees, while in Sofia the NEPs have actually covered the most portion of those tested reaches over 2/3. risky IDU - the ones with the lowest Analyzing along the lines of “attendants’’ social status. Thus through their activity - “non-attendants’’ it is worthwhile mention- they have limited the impact of this more ing several characteristics of IDU taking risky group both on the less risky IDU, shape in the course of the socio-demo- and on the country's population on the graphic analysis. whole. HIV testing data manifest that one of In the first place, closer look at findings the factors for the absence of a great num- would suggest that the extremely young ber of infected persons among IDU is the age of the new IDU (especially outside of activity of this type of organizations. Sofia) poses a serious risk which NEP have Comparing the HIV testing data it is seen not developed the tools to counter. that the attendants, regardless of their more Probably the harm reduction programmes

53 Chart 32. Comparison of HIV tested

N=501 might be able to enter schools via educa- may attempt to change the attitudes among tional programs thus raising the awareness the Roma communities through active work of their activity among the IDU at school with their leaders56. age. On the other hand, it must be borne in In conclusion the issue arises of what are mind that the average age of Bulgarian drug the problems faced by harm reduction pro- dependents will continue to go up, hence grammes? Probably the harshest one faced NEP will have to prepare themselves for is the change in the way drug distribution work with older IDU. networks work. If at the launch of Bulgarian Secondly, as the survey demonstrated, NEPs (1998-2000) most sales in the cities the parents are an utterly important factor were conducted at places where drug for IDU - they live with them and are their dependents by tradition got together, after main source of income. In view of this NEP 2001 transition took place of sales over can try and reduce risky behaviour via mobile phones. Turning pre-paid cards for developing programmes to reach out to the mobile phones into a mass service, the parents. Provision of needles and syringes, street sale patterns finally gave way. test results, etc. Active forms of work with According to survey data 69% of the inter- the families of the drug users. viewees already use this pattern, the single Thirdly, as demonstrated by experience, exception to this domination being Plovdiv the actions of the Roma communities in (see Table 38). Sofia and Bourgas lead to evident results. Transition to GSM sales creates serious Along these lines NEPs in cities like Plovdiv difficulties for NEP - if earlier it was enough

Table 37. Tested IDU by cities

Bourgas Pleven Plovdiv Sofia Number of tested 46 48 52 145 Percent of all interviewees 46,5 48,0 52,0 72,1 N=501

56 Experience from various social programmes has demonstrated that the local Roma leaders have extremely high influence within their ethnic group.

54 Table 38. Comparison of the 4 cities by drug procurement

Bourgas Pleven Plovdiv Sofia Average Dealer contacted on the phone 94,9% 80,0% 26,0% 72,1% 69,0% Dealer met in the street 16,3% 19,0% 73,0% 55,8% 44,0% Dealer visited at his/her apartment 1,0% 8,0% 22,0% 8,1% 9,5% Dealer at a cafe, bar, or restaurant 6,1% 14,0% 4,0% 14,7% 10,7% N=501 for them to be present at places where IDU the ,,one-time dose’’57, the “mobile phones get together to be able to buy the drugs they and secret places’’ pattern will irreversibly need, in 2002 - 2003 things change rapidly. oust the old forms of drug distribution. The For their own security the street drug deal- NEPs have been trying to adapt them- ers start arranging their sales at various selves to the new sales schemes since places within the city. As a result it becomes as early as they emerged, yet the latest ever more difficult to reach IDU. As seen legislative vents raise concerns that from Table 35, at the time of carrying out the under the new conditions this is extreme- survey (the summer of 2003), the old model ly hard. As practice has demonstrated, of buying at a place was still sustained harm reduction programmes have so far (street dealer or dealer's apartment) in been the only organizations actively seeking Plovdiv and Sofia, while in a city like access to marginalized groups of IDU. Bourgas, where the police is really very Without any changes to the legal frame- active, it has almost disappeared (especial- work, however, the threat is real that the ly with the apartments). Along these lines it society may lose a major channel for is very important to bear in mind that with access to these hermetic groups of IDU58. the amendment of the law and the denial of

57 As at present the dealer and the buyer are equally vulnerable from a legal point of view. 58 The currently existing law in practice allows for the programmes ,,attendants’’ to be prosecuted by the law enforcement.

55 Notes